Blunt diaphragmatic rupture (BDR) is uncommon with a reported incidence range of 1%–2%. The true incidence is not known. Bilateral BDR is particularly rare. We presented a case of bilateral BDR and we think that the incidence is under-recognised thanks to an easily missed and difficult to diagnose right sided injury. Keywords: Blunt, Diaphragm, Bilateral, Injur

Andrew L. Tang

Bellal Joseph

Donald Green

Gary Vercruysse

Lynn Gries

Maria Michailidou

Narong Kulvatunyou

Peter Rhee

Randall S. Friese

Terence O'Keeffe

Trauma Case Reports

AbstractBlunt diaphragmatic rupture (BDR) is uncommon with a reported incidence range of 1%–2%. The true incidence is not known. Bilateral BDR is particularly rare. We presented a case of bilateral BDR and we think that the incidence is under-recognised thanks to an easily missed and difficult to diagnose right sided injury

Michailidou, Maria

Kulvatunyou, Narong

Joseph, Bellal

Gries, Lynn

Friese, Randall S.

Green, Donald

O'Keeffe, Terence

Tang, Andrew L.

Vercruysse, Gary

Rhee, Peter

Elsevier - Publisher Connector 

Blunt bilateral diaphragmatic rupture—A right side can be easily missed 

Trauma Case Reports 1 (2015) 84–87
Contents lists available at ScienceDirect
Trauma Case Reports
j ou rna l homepage: ht tp : / /www. journa ls .e lsev ie r .com/
t rauma-case- repor ts /Case Report
Blunt bilateral diaphragmatic rupture—A right side can be
easily missed
Maria Michailidou, Narong Kulvatunyou ⁎, Bellal Joseph, Lynn Gries,
Randall S. Friese, Donald Green, Terence O'Keeffe, Andrew L. Tang,
Gary Vercruysse, Peter Rhee
Division of Acute Care Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave., Room 5411, PO Box 245603, Tucson, AZ, USAa r t i c l e i n f o⁎ Corresponding author. Tel.: +1 520 626 0889; fax
E-mail address: nkulvatunyou@surgery.arizona.edu
http://dx.doi.org/10.1016/j.tcr.2015.10.006
2352-6440/© 2015 The Authors. Published by
(http://creativecommons.org/licenses/by/4.0/).a b s t r a c tArticle history:
Accepted 19 October 2015
Available online 26 November 2015Blunt diaphragmatic rupture (BDR) is uncommon with a reported inci-
dence range of 1%–2%. The true incidence is not known. Bilateral BDR
is particularly rare. We presented a case of bilateral BDR and we think
that the incidence is under-recognised thanks to an easily missed and
difﬁcult to diagnose right sided injury.
© 2015 The Authors. Published by Elsevier Ltd. This is an open access
article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).Keywords:
Blunt
Diaphragm
Bilateral
InjuryIntroduction
Blunt diaphragmatic rupture (BDR) is uncommon. Contemporary series reported an incidence of only 1%
to 2% [1,2], but the reported incidencemight be underestimated, given the paucity of publishedmodern series
that liberally use computed tomography (CT) and the theoretical assumption that the diagnosis of right-sided
injury can be missed and underreported. Bilateral BDR is particularly rare. To our knowledge, 5 case reports
have been published thus far (Table 1). We herein present a case of bilateral BDR. In light of our patient's
presentation, we believe that bilateral BDR may be underreported because of an easily missed (both intraop-
eratively and postoperatively) right-sided injury.Case
A 16-year-old male unrestrained backseat passenger was brought to our trauma bay after a high-speed
motor vehicle collision with a rollover. He suffered multiple injuries, including traumatic brain injury;: +1 520 626 5016.
(N. Kulvatunyou)
Elsevier Ltd. This is an open access article under the CC BY license
Table 1
Case-reports of bilateral blunt diaphragmatic rupture.
Age (years) Sex Mechanism Delay in diagnosis (days)
1. Salah AA et al.a 12 Female Back seat unrestrained MVCf 2
2. Sirbu H et al.b 67 Male MVC 10
3. Anderson DW et al.c 42 Male Blunt chest trauma noneg
4. Wyffels PL et al.d 17 Male MVC noneg
5. Bryant LR et al.e 19 Male Front passenger MVC 14
6. Michailidou et al. 16 Male Back seat unrestrained MVC 17
a Lung India 2011; 28(3): 212–215.
b Hernia 2005; 9(1): 90–92.
c J Trauma 2002; 52: 560–561.
d Am J Surg 1984; 147: 414–417.
e J Trauma 1978; 18(4): 280–282.
f MVC = motor vehicle collision.
g Both diaphragmatic injuries were discovered during the initial operation.
85M. Michailidou et al. / Trauma Case Reports 1 (2015) 84–87complex pelvic fractures; spleen, liver, and renal injuries; and left diaphragmatic rupture. His initial chest X-
ray (CXR) revealed his stomach herniating inside his left chest. He underwent immediate laparotomy and
repair of his left diaphragm. Intraoperatively, the surgeon examined the right diaphragm by palpation and
noted no abnormality. Postoperatively, the patient had a prolonged ventilator-dependence. His daily CXR
showed right-sided diaphragmatic abnormality (Fig. 1) but was nonspeciﬁc. We performed a dynamic ultra-
sound to evaluate the right diaphragm; the result suggested that the right diaphragmwas paralysed, probably
secondary to right phrenic nerve injury. On 3 occasions (post-injury day 0, 4, and 15), the patient underwent
CT of the chest; none of those 3 scans reported right-sided diaphragmatic injury, despite the presence ofFig. 1. The post-injury daily chest X-ray showed right-sided diaphragmatic abnormality but was nonspeciﬁc.
A B
Fig. 2. Chest computed tomography demonstrates radiographic signs diagnostic for diaphragmatic injury (Panel A – “Hepatothorax” sign, arrow head. Panel B – “hump” sign, white arrow; “collar” sign,
black arrow; “band” sign, black arrow line).
86
M
.M
ichailidou
etal./Traum
a
Case
Reports
1
(2015)
84–87
87M. Michailidou et al. / Trauma Case Reports 1 (2015) 84–87“hepatothorax”, as well as “hump”, “band”, and “collar” signs (Fig. 2). Eventually, on post-injury day 17, the
patient underwent a diagnostic laparoscopy; we found the liver herniating into the right chest. We reduced
the herniated liver and performed an open repair of his right-sided diaphragmatic rupture
Discussion
Although BDR has been extensively described in the literature over the past several decades [1,2], little has
been written about bilateral BDR. Even the diagnosis of unilateral BDR remains a challenge for trauma
surgeons, particularly when it involves right-sided diaphragmatic injury. Our bilateral BDR case highlights
how difﬁcult it is to diagnose a right-sided injury. We would like to underscore the following salient points
that the literature has not emphasised.
First, right-sided diaphragmatic injury can be easily missed during exploration and repair of left-sided
injury. Of the 5 previous case reports of bilateral BDR, 3 noted the same miss.
Some authors have suggested that right sided injury has not beenmissed but instead represents a delayed
rupture secondary to ischemic changes of devitalisedmuscles. On the contrary, we believed that our patient's
right-sided injury was initially small and escaped our detection during the initial exploration; then, over the
course of our patient's hospital stay, his right-sided injury becamemore prominent and clinically detectable.
Second, diagnosing right-sided BDR is not easy for a number of reasons.With a left-sided injury, the stom-
ach, colon, and spleen can easily herniate into the chest cavity; in contrast, with a right-sided liver, the liver
cannot easily herniate into the chest cavity. In fact, the liver is known to have a protective effect, so a small
right-sided injury can easily go undetected. Only when the right-sided injury or defect becomes large enough
that liver herniates into the chest cavity can a radiologic diagnosis be made.
Another reason that diagnosing the right-sided BDR is not easy is the use of positive-pressure ventilation.
Our patient's diagnosis was more difﬁcult, and delayed, because of his prolonged positive-pressure ventila-
tion. Previously, several authors pointed out that positive-pressure ventilation can delay diagnosis [3,4]. As
Karmy-Jones et al. [4] reasoned, only when the thoracic positive pressure comes down (as a patient is being
weaned off the ventilator) could the abdominal–thoracic pressure gradient increase and create enough
abdominal pressure to push visceral organs into the chest cavity.
Third and ﬁnally, we need to stress the utmost importance of trauma surgeons recognising all the CT ﬁnd-
ings suggestive of possible diaphragmatic injury. Several radiologic studies highlighted some of the key signs,
particularly those involving the right side: a continuity defect of the diaphragm; a “dependent viscera” sign
which involves visceral organs (bowel, liver) herniating through the diaphragmatic defect and touching the
posterior chest wall; a constricting “collar” sign, best seen in a coronal view (Fig. 2, Panel B, black arrow)
but sometimes seen in an axial view; a “hump” sign (Fig. 2, Panel B, white arrow), which is speciﬁc for a
right-sided diaphragmatic injury with herniating liver; and a “band” sign, which is a lucency line or band
across the diaphragmatic defect (Fig. 2, panel B, black arrow line). Trauma surgeons must be vigilant
concerning these signs: the ﬁrst or second CT scan may not demonstrate them if the diaphragmatic defect
is initially small.
In conclusion, our patient's right-sided injury was missed intraoperatively and remained difﬁcult to
diagnose postoperatively, adding to the evidence that bilateral BDR is most likely underreported. Because
right-sided injury can so easily go unnoticed, trauma surgeons must be aware of all pertinent CT signs, in
order to make an accurate diagnosis early and avoid complications.
References
[1] T. Chughtai, S. Ali, P. Sharkey, et al., Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases,
Can. J. Surg. 52 (3) (2009) 177–181.
[2] J.D. Lewis, S.L. Starnes, P.K. Pandalai, et al., Traumatic diaphragmatic injury: experience from a level I trauma center, Surgery 146
(2009) 578–584.
[3] R. Karmy-Jones, Y. Carter, E. Stern, The impact of positive pressure ventilation on the diagnosis of traumatic diaphragmatic injury,
Am. Surg. 68 (2002) 167–172.
[4] M.R. Taheri, E.J. Stern, "Delayed" right diaphragmatic rupture because of positive pressure mechanical ventilation, Curr. Probl. Diagn.
Radiol. 41 (4) (2012) 133–135.


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