A Case of Diaphragmatic Hernia and Delayed Hemothorax caused by Rib Fractures

Abstract

We performed an emergency surgery for a case of delayed hemothorax and traumatic diaphragmatic hernia which developed 4 weeks after the patient had fallen.

A 70-year-old woman who had fallen at home and got a bruise on the left-sided chest visited a neighboring hospital on the next day and was diagnosed with multiple left rib fractures. She had been followed until 15^th day after the trauma when she was referred to our hospital because of an increasing tendency of pleural effusion. She underwent a thoracentesis with 550 ml of bloody discharge. As satisfied pulmonary expansion was regained with this procedure, we decided to follow her in the clinic. On the 28^th post-traumatic day, she presented to our hospital again because of cough and dyspnea. Large quantities of left pleural effusion were present. A contrast-enhanced CT scan confirmed aggravated left hemothorax associated with extravascular leakage around the left 9^th fractured rib. Then we performed emergency thoracoscopic removal of hematoma, and added an 8-cm small thoracotomy, through which we identified a one-cm hernia orifice at the diaphragm and the greater omentum protruding from the orifice. Traumatic diaphragmatic hernia was thus diagnosed. The greater omentum was reduced into the abdominal cavity and the diaphragmatic hernia was repaired. The postoperative course was uneventful and she was discharged from our hospital on the 11^th hospital day.

As with this case it is etiologically inferred that pieces of the fractured bone repeatedly contacted with the diaphragm with respiratory movements, leading to delayed diaphragmatic hernia.