Answer

Diaphragmatic rupture

There is an opacity in the left hemithorax above the left hemidiaphragm on the first film. The second film demonstrates a nasogastric tube above the diaphragm in the stomach [verified after CT (Fig. 3.12)]. This has passed into the left hemithorax through a rupture in the left hemidiaphragm.

Diaphragmatic rupture can follow either blunt or penetrating abdominal trauma but patients may be asymptomatic for months or years

Fig. 3.12 Diaphragm rupture CT. The stomach and mesenteric fat has herniated into the left hemithorax. Other signs of traumatic diaphragmatic rupture on CT include discontinuity of hemidiaphragm/abnormal contour, herniation of colon, small bowel or abdominal contents into chest.

Fig. 3.13 Diaphragm rupture. Coronal reformat. The outline of the diaphragm is lost and the stomach is seen herniated into the left hemithorax.

following trauma. Up to 90% of diaphragmatic ruptures diagnosed are left sided. Injuries frequently associated with diaphragmatic rupture include

■ fracture of lower ribs,

■ perforation of hollow viscus,

Diaphragm rupture can be a difficult diagnosis to make. When gross, chest X-ray changes include bowel loops, nasogastric tube present in the chest, but signs may only be subtle such as loss of contour of the diaphragm silhouette. If there is herniation of a hollow viscus into the chest there may be constriction at the point of herniation - collar sign. The most common finding on CT is abrupt discontinuity of the diaphragm. Sagittal and coronal reformatted images can improve the sensitivity and specificity of CT in making the diagnosis (see Fig. 3.13).

Fig. 3.14 Quiz case.

36-year-old male. Road traffic accident. Left upper quadrant pain, free fluid seen on ultrasound (Fig. 3.14).

■ What is the management of this condition?

Fig. 3.14 Quiz case.

Answer Splenic laceration

The contrast enhanced CT scan shows a large splenic laceration with haematoma in the left upper quadrant which is surrounding the spleen.

Management of blunt splenic trauma

The spleen is the most commonly injured organ in the abdomen. Ultrasound can demonstrate splenic laceration, adjacent fluid (Fig. 3.15) or splenic haematoma, but the technique is often limited by pain and patient immobility. Contrast enhanced CT gives excellent visualisation of the left upper quadrant and in many hospitals it is now the preferred modality of imaging. It will also demonstrate any associated injuries, e.g. renal injury or rib fractures. Just under a half of patients with splenic injury have left-sided rib fractures. Splenic injury can be acute or delayed (usually due to rupture of subcapsular haematoma). Delayed rupture is usually in the first 7-10 days following the injury. Injuries may occur inadvertently during abdominal surgery or following trivial trauma especially if the spleen is abnormal, e.g. malaria or infectious mononucleosis.

Surgical opinion varies regarding the need for splenectomy. Although splenic trauma grading systems exist (Table 3.1) these are not a good predictor of which patients require splenectomy.

The subsequent risk of pneumococcal infection means that surgical 140 splenectomy is avoided where possible. Patients with cardiovascular

ultrasound demonstrating free peritoneal fluid. In the setting of blunt abdominal trauma this is usually haemoperitoneum.

Fig. 3.15 Abdominal ultrasound demonstrating free peritoneal fluid. In the setting of blunt abdominal trauma this is usually haemoperitoneum.

Fig. 3.15 Abdominal

Table 3.1 Grading of splenic injury

1. Minor subcapsular tear or haematoma

2. Parenchymal injury not extending to hilum

3. Injury involving vessels and hilum

4. Shattered spleen instability require resuscitation and early surgery. Surgical options include splenectomy or splenic repair (splenic conservation needs to preserve more than 20% of tissue).

Approximately one-third of patients fail conservative management. Monitoring should include cardiovascular signs and haematocrit. Children can often be managed conservatively as they have an increased proportion of low grade injuries and they have fewer multiple injuries.

If conservative management is successful, then patients should have limited physical activity for 6 weeks and play no contact sports for 6 months. Complications following splenic trauma include recurrent bleeding, delayed rupture and pseudoaneurysm formation (Fig. 3.16). Pseudoaneurysm formation is a common cause for failure of non-operative management. This is diagnosed by identifying an intra-parenchymal contrast blush on CT or using angiography. Acute bleeding at the time of injury and delayed pseudoaneurysm formation can both be treated with coil embolisation (Fig. 3.17).

Fig. 3.16 Angiogram: 1 week following blunt splenic trauma. Multiple pseudoaneurysms are demonstrated.

Fig. 3.17 Angiogram following coil embolisation of pseudoaneurysms. The spleen is preserved following blunt splenic trauma whenever possible to reduce the risk of subsequent infection. Aggressive imaging follow-up and coil embolisation have helped to reduce the rate of splenectomy for blunt abdominal trauma.

Fig. 3.17 Angiogram following coil embolisation of pseudoaneurysms. The spleen is preserved following blunt splenic trauma whenever possible to reduce the risk of subsequent infection. Aggressive imaging follow-up and coil embolisation have helped to reduce the rate of splenectomy for blunt abdominal trauma.

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