Traumatic diaphragm injury caused by rib fracture without preoperative diagnosis

Abstract

Traumatic thoracic injury has many causes. Diaphragm injury should be cited as a differential diagnosis. We encountered traumatic diaphragm injury that was not detected by preoperative imaging. The patient was a 32-year-old man with a past medical history of epilepsy. After epileptic seizure, he complained of right chest pain and dyspnea. A chest radiograph revealed a right pneumothorax and he received chest drainage. On the next day, anemia showed progression. Chest CT revealed massive pleural effusion, multiple rib fractures and ascites. Three-dimensional (3D) reconstruction showed 7-9th rib fractures and displacement of the fractured 8th rib. Angiography was performed for hemostasis, although we could not detect active bleeding vessels. Then, we performed an emergency operation to search for intrapleural organ injury and repair the organ. We noted that the displaced 8th rib had entered the intrapleural space. There was diaphragm injury directly under the rib fracture. We carefully looked for other injuries and then closed the chest. He was discharged on the 6th day after surgery without any complications. It was difficult to diagnose diaphragm injury without hernia. Surveillance for organ injuries should not be performed solely based on imaging. Diaphragm injury may be a cause of hematothorax, and careful introperative surveillance is critical.