In a patient  hospitalised following a motor vehicle accident,

a)   What    findings   on   patient    assessment    would   suggest   the   presence   of   traumatic diaphragmatic rupture?

b)  Briefly  outline  the  abnormal findings  you would  seek  on  rectal examination and  their clinical significance if the patient  was unconscious.

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College Answer

Diaphragm rupture; 
a) Frequently no direct symptoms or signs referable

b) Shoulder pain
c) Left >> right, usually associated with other injuries

d) Intrathoracic bowel
e) Obscured diaphragm shadow on CXR
f)_If delayed presentation – post prandial epigastric or thoracic pain

g) Rarely gastric herniation or volvulus

Rectal examination:
a.   Absent anal tone  - cord lesion (unless relaxants administered)
b.  Palpable sphincter rupture
c.   Displaced (high riding) prostate – ruptured urethra
d.  High tenderness in anterior quadrants – ruptured viscus e.   Pelvic haematoma – pelvic fracture
f.   Palpable bony disruption – sacro-coccygeal / pelvic fracture

g.   Visible external lacerations / bleeding.

Discussion

Traumatic diaphragmatic rupture is usually pretty obscure.

Radiological findings are usually all the findings you get. The CXR is usually diagnostic.

However, one can occasionally unearth some of the following (non-specific) clinical features:

  • Hypoxia
  • Decreased air entry on the affected side
  • Decreased chest excursion on the affected side
  • Dull percussion note
  • Bowel sounds in the chest
  • Ileus and bowel obstruction due to volvulus
  • Shoulder pain
  • Stool or bile in the chest drain

As for the rectal examination; one looks for

  • Sphincter tone (cord injury)
  • Gross blood (GI tract injury)
  • Swelling (pelvic haematoma)
  • "High riding" prostate - urethral injury
  • Mobile coccyx- sacral or coccygeal fracture
  • Obvious external anal damage
  • Disrupted rectal wall integrity

According to a recent review, the PR changed management in 1.2% of observed cases.

LITFL have some choice words about this investigation.

 

References

References

García-Navarro, Ana, et al. "[Traumatic diaphragmatic rupture]." Cirugia espanola 77.2 (2005): 105-107.

Morley, J. E. "Traumatic diaphragmatic rupture." Hospital 30.80 (1974): 1.

Willsher, Peter C., and Richard J. Cade. "Traumatic diaphragmatic rupture."Australian and New Zealand Journal of Surgery 61.3 (1991): 207-210.

Simpson, J., et al. "Traumatic diaphragmatic rupture: associated injuries and outcome." Annals of the Royal College of Surgeons of England 82.2 (2000): 97.

Porter, John M., and Caesar M. Ursic. "Digital rectal examination for trauma: does every patient need one?." The American surgeon 67.5 (2001): 438-441.