Teaching Case

Thoracic pain after traffic accident

One week after blunt trauma ( traffic accident ), a young male driver complained of thoracic pain and increasing dysphagia. At day one, a chest X-ray was read as normal ( figure 1 ). At day seven, a new chest X-ray was performed, followed by an oesogastric contrast study and thoracic MRI.

Blunt trauma in the young male population (drivers) is the usual cause of traumatic diaphragmatic rupture (incidence : 0.8 to 1.6 % of the patients admitted to the hospital with blunt trauma (1)). There is a significative left-sided rupture preponderance (left : 68.5% ; right : 24.2% ; bilateral : 1.5% (1)). Hernia content depends on tear size, violence of trauma and delay in diagnosis. The diagnosis is frequently missed in the acute phase (no specific clinical feature, urgent care for associated injuries) and the rupture is the most often diagnosed peroperatively (before surgery : 31% ; during surgery : 63% ; after surgery : 4.5% (2)). In acute conditions, careful examination of adequate CXR will suffice for the diagnosis. Presence of gas bubbles or loop of air-filled bowel in the chest are pathognomonic. In most subtle instances without associated injuries, additional steps are required to establish the diagnosis. Increased CXR sensitivity by gastrografin study and/or nasogastric tube, and ultrasonography ( especially for the right-sided lesions ) may be particularly helpful for the diagnosis. When the patient is stabilized and associated injuries are controlled, sagittal and coronal MRI studies will show with high sensitivity and specificity the diaphragmatic tear and the associated injuries. Associated injuries are responsible for the high mortality (17% (1)) and morbidity, principally because of pulmonary complications. Surgical repair is the rule.