DIAGNOSTICS AND TREATMENT OF DIAPHRAGMATIC INJURIES IN A CHILD WITH POLYTRAUMA
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Diagnostics and treatment of diaphragmatic injuries is one of the unsolved problems of urgent surgery. Such pathology is one of the relatively poorly studied, but most severe types of injuries in patients with associated injury to the chest and the abdomen [1-4]. Diaphragmatic injuries are identified in 0.5-5 % of all cases of associated injury [5]. Such injuries are commonly localized to the left, in the region of the central tendon of the diaphragm or along clefts between individual muscular groups. The ratios between a diaphragmatic rupture to the left and to the right are 84 % and 16 % according to the literature data [6, 7].
Some special difficulties are associated with diagnostics of associated thoracic injury with lung injury and hemopneumothorax. Diagnostics of closed diaphragmatic injuries sometimes causes some difficulties even in presence of the modern diagnostic methods [8]. The diagnostic difficulties are conditioned by multiple symptoms of clinical picture, severity of patient’s condition, absence of specific symptoms of diaphragmatic injuries, associated injuries to the thoracic and abdominal organs [9].
The leading role in diagnostics of diaphragmatic injuries relates to the radiologic technique, but currently it is combined with ultrasonic examination or thoracoscopy. Diagnostics of diaphragmatic injuries is possible during laparoscopy upon condition of overlapping limited pneumoperitoneum, because of possible development of tension pneumothorax [8].
Treatment of diaphragmatic injuries is only urgent. A surgical approach depends on location of bleeding source in patients who are operated for intraabdominal or intrapleural bleeding within the first hours after injuries. Laparotomy is a method of choice for operations concerning identified diaphragmatic ruptures to the left. Thoracotomy is optimal for a rupture to the left [4, 9].
The clinical case
A child (age of 14) was admitted by the instant readiness team to Regional Clinical Center of Miners’ Health Protection 24 hours after the injury. The transfer was realized with a reanimobile and the Kashtan anti-shock suit (Fig. 1).
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Figure 1 The patient S., age of 14, upon admission
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Figure 2 SCT and X-ray examination of the pelvic bones
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From the history: the patient was in state of alcohol intoxication and suffered from a road traffic injury as a passenger in a car. The emergency team transferred the patient to a medical prophylactic institution according to his place of residence. Diagnostic laparoscopy was conducted after the examination (plain radiology of the chest and the skeletal injury) and anti-shock measures. It found a hematoma in the region of the hepatic angle of the colon, about 30 ml of the blood in the abdominal cavity, without signs of ongoing bleeding. A drain was installed into the subhepatic region. The diagnosis was made: “Polytrauma. A closed chest injury. A closed uncomplicated fracture of the ribs 9, 10 and 11 to the right. Minimal pneumothorax, hydrothorax to the right. A closed fracture of the right iliac wing, a fracture of ischial bone to the right with displacement. A fracture of the right acetabular roof. A closed fracture of both bones of the right forearm in the distal one-third with displacement of fragments. Blunt abdominal trauma, contusion of anterior abdominal wall, liver contusion, condition after diagnostic laparoscopy, abdominal cavity draining. Brain concussion. Surgically prepared wounds in occipital region to the right and along posterior surface of the right ulnar joint”.
Considering the severity of state, the child was transferred to the specialized center of Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky. After arrival to our center the patient’s condition was severe because of the associated injury (thoracoabdominal, skeletal and traumatic brain injury). The patient was immobilized by means of the Kashtan anti-shock suit. The child was conscious and in drowsy state. A response to the examination was adequate with moderate noncriticality. The palpebral fissures and the pupils were equal, ocular motility was within the full range. The photoreaction was persistent. Small swinging horizontal nystagmus was in border-line abduction of the eyes. The face was symmetrically innervated. The tongue was straight. Phonation and swallowing were not disordered. Muscular tone in the extremities was normal. The right upper extremity was immobilized with a plaster splint. There was no visible deformation in the pelvic region. Palpation of the pelvic bones was painful. The skin surface and the visible mucosa were pale pink and with satisfactory moisture. A surgically prepared wound of the soft tissues in the occipital region to the right (5 cm) was sutured with interrupted sutures. There were some grazes along the lateral surface of the chest. The chest was symmetrical, the right side retarded during respiration. There were a deformation, edema and palpation tenderness in the region of the left clavicle. There was percussion obtundation of pulmonary sound over the whole right surface of the chest. During auscultation the breathing was weak to the right and vesicular to the left, without stertor. RR – 24 per min. Heart tones were rhythmical. HR – 104 beats per min. AP – 110/65 mm Hg. The abdomen was right-shaped and symmetrical. There was a drain tube in the right hypochondrium, with hemorrhagic discharge. As result of diagnostic laparoscopy, there were some wounds above the omphalos to the left. The sutures were normal. During palpation the abdomen was soft and painful in the region of the postsurgical wound and the drain tube. There were no peritoneal symptoms. Auscultation indicated decreased intestinal peristalsis. The liver and the spleen were near the edge of the costal arch during palpation and auscultation. Intestinal habit was not disordered. Diuresis was adequate. Urine was without visual changes.
The additional examination was conducted in out center:
– Cervical X-ray imaging with two planes: no bone injuries.
– Cerebral helical CT: no structural changes in the brain, no injuries to cranial bones.
– X-ray imaging and helical CT of the pelvis: a longitudinal fracture of the crest of the ischial bone from the upper edge with transition to the right iliac bone, a transverse fracture with displaced fragments, a fracture of acetabular roof with displacement. A right-sided displaced fracture of the ischial bone (Fig. 2).
– X-ray examination of the left clavicle: a fracture of the left clavicle in the middle one-third with displaced fragments.
– X-ray examination of the right forearm: a fracture of both bones of the right forearm with displaced fragments.
– Plain X-ray examination, helical CT of the chest: fractures of the ribs 9, 10 and 11 to the right, without displacement. Some signs of pneumothorax and hemothorax to the right. A contusion of the right lung, ARDS of degree 2, a high position of a cupula of the diaphragm to the right (Fig. 3).
Figure 3
Plain radiography and CT of the chest of the patient S., age 14. The high position of the cupula of the diaphragm to the right
According to the results of the examination the urgent draining of the right pleural cavity (according to Bulau) was conducted for 4th intercostal space along the anterior axillary line. After consideration of the radiologic data (the high position of the right cupula of the diaphragm) a rupture of the right cupula of the diaphragm was suspected. A solution about diagnostic laparoscopy was made because of presence of a closed abdominal injury, hemorrhagic discharge from the abdominal cavity, and presence of a pleural drain. Laparoscopy was conducted with minimal pressure to the abdominal cavity (8 mm Hg) and minimal amount of the gas. The examination of the abdominal cavity showed some hemorrhagic discharge and blood clots along the right lateral canal. There was a non-tense subcapsular hematoma in the region of the right lobe of the liver. The hepatic angle of the colon was examined and a tense subserous hematoma was found. There was no discharge in the small pelvis and along the left lateral canal. The spleen was without changes. The examination of the right cupula of the diaphragm showed a rupture in the central department (about 10 cm). A decision was made about right-side thoracotomy.
Anterior lateral thoracotomy was conducted for 6th intercostal space to the right. There were about 300 ml of hemorrhagic fluid in the pleural cavity. A lineal rupture (about 10 cm) was found in the central part of the right cupula of the diaphragm. The diaphragmatic surface of the liver prolapsed through the rupture (Fig. 4). The further revision showed a rupture (2 cm) in the lower lobe of the right lung in the plane of 6th segment. A diaphragmatic rupture was sutured according to the type of duplication (Fig. 5). A lung rupture was sutured with individual interrupted sutures (Fig. 6). The right pleural cavity was drained: a drain tube was installed into 8th intercostal space along the middle subaxillary line, a drain tube in 4th intercostal space – along the anterior subaxillary line. Layer suturing of the wound was made.
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Figure 4 Thoracotomy, a rupture of the right cupula of the diaphragm with visually accessible liver
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Figure 5 Thoracotomy, suturing the rupture of the right cupula of the diaphragm
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Figure 6 Thoracotomy, a rupture of pulmonary tissue in the region of 6th segment of the right lung
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The single stage surgery was made – opened reposition of the left clavicle, osteosynthesis with the plate and screws. Open reposition of the radial and ulnar bones in the middle one-third of the right forearm, and K-wire fixation were made (Fig. 7). Skeletal traction from the right calcaneal bone was made with K-wire and the weight of 5 kg.
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Figure 7 Reposition of radial and ulnar bones of the distal one-third of the right forearm; fixation with K-wire
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Figure 8 Plain radiography and SCT of the chest on 10th day after surgery; right-side lower lobe pneumonia
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The diagnosis was made on the basis of the conducted examination and surgical management: “Polytrauma. A closed thoracic injury. A closed uncomplicated fracture of the ribs 9, 10 and 11 to the right. A contusion and a rupture of 6th segment of the right lung. Right-side hemo-pneumothorax. A rupture of the right cupula of the diaphragm. A closed abdominal injury, contusion of the right lobe of the liver, subserous hematoma of the hepatic angle of the colon. A closed fracture of the crest of the right iliac bone, a displaced fracture of the ischial bone to the right. A fracture of the roof of the right acetabulum. A closed displaced fracture of both bones of the right forearm in the distal one-third. Brain concussion”.
After surgery the child was treated in the ICU during 18 days. The treatment included ALV, infusion therapy, transfusion of blood components, symptomatic therapy, antibacterial therapy, analgesia and dressings. The postsurgical period was complicated by the course of posttraumatic lower lobe pneumonia to the right (Fig. 8). ALV lasted for 10 days. A pleural cavity draining tube was removed on the day 8. Within the following 23 days the treatment was conducted in the pediatric orthopedics and traumatology department: anti-inflammatory therapy, physical therapy, therapeutic exercises. K-wires were removed from the right forearm on 21st day. The union of the fractures of the bones of the right forearm, the left clavicle, the ribs 9, 10 and 11 and the pelvic bones was noted. On 41st day the patient was discharged in satisfactory condition with the restored functions of the body.
CONCLUSION
Diaphragmatic injuries in closed abdominal trauma are often diagnosed lately, because their manifestations are disguised by some symptoms of injuries to other organs of abdominal or pleural cavities in the acute period of trauma. One should note that a diaphragmatic rupture (especially on the right side) is often not diagnosed during laparoscopy for abdominal injuries, and it results in recurrent surgery within various time intervals after trauma. Therefore, a surgeon should be cautious in point of a possibility of such injury in a patient with polytrauma.