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Strangulated intercostal liver herniation subsequent to blunt trauma. First report with review of the world literature
Cino Bendinelli, Andrew Martin, Shane D Nebauer, Zsolt J Balogh
World Journal of Emergency Surgery , 2012, DOI: 10.1186/1749-7922-7-23
Abstract: Following blunt trauma, a 61-year old man developed a traumatic transdiaphragmatic intercostal hernia complicated by strangulation of liver segment VI. Due to pre-existing respiratory problems and the presence of multiple other injuries (grade III kidney laceration and lung contusion) the hernia was managed non-operatively for the first 2?weeks.The strangulated liver segment eventually underwent ischemic necrosis. Six weeks later the resulting subcutaneous abscess required surgical drainage. Nine months post injury the large symptomatic intercostal hernia was treated with laparoscopic mesh repair. Twelve months after the initial trauma, a small recurrence of the hernia required laparoscopic re-fixation of the mesh.This paper outlines important steps in managing a rare post traumatic entity. Early liver reduction and hernia repair would have been ideal. The adopted conservative approach caused liver necrosis and required staged procedures to achieve a good outcome.
Laparoscopic Treatment of a Rare Right Diaphragmatic Rupture with Small Bowel Herniation after Blunt Thoracic Trauma  [PDF]
H. Hoffmann,D. Oertli,O. Heizmann
Minimally Invasive Surgery , 2010, DOI: 10.1155/2010/109062
Abstract: Blunt traumatic diaphragmatic rupture (BTDR) is a life-threatening condition with an incidence from 0,8%–1,6% in blunt trauma, mostly located on the left side. The main prognostic factors are severe side injuries and the delay of diagnosis. We present a rare case of a 68-year-old female, with an isolated right diaphragm rupture. The diagnosis was done with a delay of 4 days by thoracic radiographs, which showed a herniation of small bowel into the right thoracic cavity. A reposition of the small bowel and a closure of the diaphragmatic defect by running suture were carried out laparoscopicly. Although large prospective studies concerning the outcome of laparoscopic approach to right BTDR are still missing, we could show, that laparoscopy can be performed safely in right traumatic diaphragm rupture. 1. Introduction Blunt traumatic diaphragmatic rupture (BTDR) is a life-threatening condition with an incidence of 0.8%–1.6% in blunt trauma [1–3]. The closure of the diaphragm rupture must be performed immediately. The diagnosis often happens to be late due to the absence of typical symptoms or other major injuries dominating the clinical aspect [4]. An isolated BTDR is rare and thus might be followed by a period of weeks or months not revealing any symptoms [2, 5]. Most BTDR are located on the left side in the musculotendinous intersection [1, 3, 4]. Right BTDR are rarely described and less frequent [6]. Herniation of colon, small bowel, or liver may occur and result in ileus, necrosis, and perforation [4, 7]. 2. Narrative We present a rare case of a 68-year-old female hospitalized in the neurological department due to Parkinson disease. She fell onto a chair hitting her right hemithorax. Initially, subjective symptoms have been missing. The examination showed a slightly reduced breath without any signs of pneumothorax or dyspnea, a decent pressure pain and a bruise. 4 days after trauma, she developed a progressive pulmonal decompensation with desaturation. Additionally, there have been signs of ileus. The chest radiograph displayed a herniation of bowel into the right hemithorax with consecutive ileus signs (Figure 1). Figure 1: Chest radiograph shows bowel herniation into right hemithorax. We performed a laparoscopic approach and found a ?cm rupture of the right diaphragm with herniation of 1 meter small bowel. The bowel appeared vital after reposition. The transdiaphragmatic thoracoscopy displayed a collapsed lung and a dislocated rib fracture (Figure 2). After irrigation of the thoracic cavity we made a direct laparoscopic strainless running suture with
Diaphragmatic rupture with right colon and small intestine herniation after blunt trauma: a case report
Mirko Muroni, Giuseppe Provenza, Stefano Conte, Andrea Sagnotta, Niccolò Petrucciani, Ivan Gentili, Tatiana Di Cesare, Andrea Kazemi, Luigi Masoni, Vincenzo Ziparo
Journal of Medical Case Reports , 2010, DOI: 10.1186/1752-1947-4-289
Abstract: We report a case of a 59-year-old Italian man hospitalized for abdominal pain and vomiting. His medical history included a blunt trauma seven years previously. A chest X-ray showed right diaphragm elevation, and computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy, at which time the colon and small intestine were reduced back into the abdomen and the diaphragm was repaired.This was a unusual case of traumatic right-sided diaphragmatic hernia. Diaphragmatic ruptures may be revealed many years after the initial trauma. The suspicion of diaphragmatic rupture in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only curative treatment for diaphragmatic hernias. Prosthetic patches may be a good solution when the diaphragmatic defect is severe and too large for primary closure, whereas primary repair remains the gold standard for the closure of small to moderate sized diaphragmatic defects.Traumatic rupture of the diaphragm is an uncommon condition. It occurs in 0.8 to 5% of patients admitted to hospital with thoracoabdominal trauma. The etiologic factors are blunt trauma (for example, in motor vehicle accidents) and penetrating trauma [1]. The organs most commonly involved in right-sided diaphragmatic hernias are the colon, omentum, small intestines and liver.Chest radiography and computerized tomography is the most effective method for diagnosis of traumatic diaphragmatic rupture [2]. Treatment is surgical, with reduction of the viscera and simple repair of the diaphragm with non-absorbable suture.A 59-year-old Italian man presented with abdominal pain localized in the right upper quadrant, constipation and vomiting for longer than one week. The patient had inconstant symptoms including shortness of breath and dyspnea. His medical history included right-sided rib fractures in a moto
Herniation of the Colon Through Intercostal Space  [PDF]
Mahmut Tokur,Can Kürk?üo?lu,Sedat Demircan,Cüneyt Kurul
Journal of Clinical and Analytical Medicine , 2012, DOI: 10.4328
Abstract: A 55-year-old woman underwent two consecutive metastasectomy within four months due to left pulmonary metastases originated from a uterin leiomyosarcoma. Two months after the last operation she presented with a soft and lobulated mass just below her thoracotomy scar (Figure 1A-1B). Chest x-ray revealed subcutaneous air densities considered as a colon herniated through the 5th intercostal space and elevated diaphragm (Figure 1C-1D).
Late Onset Traumatic Rupture of the Diaphragm with a Minor Blunt Trauma: A Case Report  [cached]
Nazik A??l?o?lu,Atay ?zkal,Burak Tander
Journal of Academic Emergency Medicine , 2011,
Abstract: Rupture of the diaphragm after blunt trauma is uncommon in children but it is usually associated with life-threatening complications. A delay in diagnosis may result in an increased mortality and morbidity. A case of a ten month old girl with diaphragmatic rupture and gastric herniation presenting one month after a minor blunt trauma is reported in this article Diagnosis of isolated diaphragmatic rupture is difficult during the preoperative period. Following blunt or penetrating traumas, this possibility should be considered in order to diagnose diaphragmatic ruptures.
Cardiac injuries in blunt chest trauma
Marina Huguet, Catalina Tobon-Gomez, Bart H Bijnens, Alejandro F Frangi, Marius Petit
Journal of Cardiovascular Magnetic Resonance , 2009, DOI: 10.1186/1532-429x-11-35
Abstract: Blunt chest traumas are a clinical challenge, both for diagnosis and treatment, since they are often associated with substantial cardiac injury [1]. If not recognized and treated promptly, it may have severe, or even fatal, complications for the patient due to myocardial herniation [2]. Myocardial contusion usually shows enzyme rises, electrocardiographic abnormalities and contractile dysfunction [1]. Since these symptoms can be similar for acute peri-traumatic myocardial infarction, a correct diagnosis may be difficult. The use of Cardiovascular Magnetic Resonance (CMR) can play a major role in diagnosing the etiology of the cardiac abnormalities in this setting.We present two cases where the use of CMR is illustrated for the diagnosis and understanding of cardiac injury. The first patient was a 12-year-old boy referred to our center after a blunt thoracic-abdominal trauma by a rollover vehicle accident at the age of six. Although he was initially asymptomatic, a subsequent tachycardia was noted. An echocardiogram, acquired two years after the trauma, revealed a left midventricular aneurysm with loss of myocardium affecting the septal and posteriorlateral walls.The second patient was a 45-year-old man who suffered from a blunt chest trauma after precipitating into a trench in which he was buried by construction material and lost consciousness. His echocardiogram showed a ventricular-septal defect with a left to right shunt. The CMR was performed the day after the trauma.Both patients underwent an CMR examination to estimate the severity of myocardial damage using a 1.5 T scanner (Signa CVi-HDx, GE Medical Systems, Waukesha, WS) with a dedicated cardiac coil. The protocol included balanced steady-state free precession gradient-echo images (CINE) and late gadolinium enhancement (LGE) inversion recovery images (after IV administration of 0.2 mmol/kg of gadopentate dimeglumine contrast).The main structural abnormality observed in both patients was the loss of myocardiu
Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports
Peter B Sherren, Robert Galloway, Marie Healy
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-64
Abstract: We present two survivors of BTPR and cardiac herniation, one with a delayed penetrating cardiac injury secondary to rib fractures. With these two cases and literature review, we hope to provide a greater awareness of this injuryBTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with:Cardiovascular instability with no obvious causeProminent or displaced cardiac silhouette and asymmetrical large volume pneumopericardiumPotentially, with increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac Herniation could even be considered the 5th H of reversible causes of blunt traumatic PEA arrest.Cardiac herniation is a significant and potentially fatal complication of BTPR. This is by no means a new problem [1,2] and its occurrence in severe blunt trauma is in the order of 0.4% [3,4]. Despite literature experience dating back to 1864 [5], it is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma [3,6]. Of those who make it to hospital, and are later diagnosed with BTPR, the survival rate is 36.4% - 42.9% [7]. The high mortality rate is probably a reflection of not only BTPR and cardiac herniation but also the associated injuries [3].Here, we present two interesting cases of both left and right pleuropericardial ruptures and cardiac herniation. Despite the delay in initial diagnosis, both patients survived, though with varying degrees of disability secondary to related traumatic injuries. The second patient is one of the few reported cases of cardiac herniation and a delayed penetrating car
Pancreatic transection due to blunt trauma  [cached]
Ankouz Amal,Elbouhadouti Hicham,Lamrani Jihane,Taleb Khalid
Journal of Emergencies, Trauma and Shock , 2010,
Abstract: Blunt fractures of the pancreas are rare and serious lesions. An isolated injury to the pancreas is uncommon. Physical signs and laboratory parameters are often inaccurate, and missing the diagnosis can cause serious clinical problems. We report a case of a 28-year-old woman with blunt pancreatic trauma in whom computed tomography revealed a fracture through the tail of the pancreas. It was complicated by pseudocyst formation. She was treated surgically with good outcome. This case is a reminder that pancreatic injuries should be considered in the differential diagnosis in cases of blunt abdominal trauma. Also, the clinician should be aware that when pancreatic injuries are managed conservatively, the clinical, radiological, and laboratory parameters need to be monitored till resolution.
Blunt rupture of the right hemidiaphragm with herniation of the right colon and right lobe of the liver  [cached]
Bairagi Anjana,Moodley Saundrarajen,Hardcastle Timothy,Muckart David
Journal of Emergencies, Trauma and Shock , 2010,
Abstract: Acute right hemidiaphragm rupture with abdominal visceral herniation is reportedly less common than on the left. We present a complex case of blunt rupture of the right hemidiaphragm with herniation of the right colon and right lobe of the liver in a multiply injured patient. The diagnostic approach, with specific reference to the imaging studies, and surgical management is discussed, followed by a brief literature review highlighting the complexities of the case.
Clinical Factors in Geriatric Blunt Trauma
?zge DUMAN AT?LLA,Feriyde ?ALI?KAN TüR,Ersin AKSAY,Tar?k DO?AN
Turkish Journal of Emergency Medicine , 2012,
Abstract: Objectives: This study aimed to determine the clinical factors that contribute to the admission, management, and outcome of blunt trauma to geriatric patients. Methods: This prospective, cross sectional study was conducted at a tertiary Emergency Department (ED) between January and April of 2012. Patients were included if they were 65 years and older and were suffering from a blunt trauma. The demographic data, comorbid diseases, quantity of medications, mechanism of injury, history of trauma within the last six months, body region of injury, injury severity score (ISS), in-hospital length of stay (LOS), and final outcome of the patient were recorded. Results: The study included 406 geriatric patients (268 (66%) female) with a mean age of all patients being 75.6±7 years (65-102 years). Extremities and head injury were the most common injury sites. The femoral neck was the most common fracture site (24%). Low velocity fall (LVF) was the most common mechanism of blunt trauma (79%). Advancing age was also significantly related with LVF incidence, fracture incidence and ISS ≥9. Five patients died in the hospital (1.2%). Conclusions: LVF was the primary etiology for geriatric blunt trauma. The head and extremities were the most common injury sites and the femoral neck was the most common site of fracture. For fractures, advancing age and polypharmacy (≥5 agents) and for LVF, female gender was independent risk factors Advancing age and a history significant for stroke were related to the severity of the trauma.
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