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The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
The blunt cp angle in trauma pts-diaphragmatic hernias
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The blunt cp angle in trauma pts-diaphragmatic hernias

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About traumatic diaphragmatic hernias …

About traumatic diaphragmatic hernias

Incidence in the foothills of the Himalayas may be higher than the plains- relation to climbing trees for animal fodder or falls from roads in hills onto trees or slopes
Every blunting of CP Angle in trauma pts must raise the possibility
Varied clinical spectrum.
Can be repaired by general surgeons themselves with good results
Associated injuries often influence the eventual outcome

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  • 1. The Blunt C/P Angle in trauma patients – BEWARE!Traumatic diaphragmatic hernias-Acommon entity in hilly regions with a varied presentation Dr Alok Vardhan Mathur, Dr Mohan Singh , Dr K. K. Sinha, Dr Madhukar Maletha, Dr J P Sharma, Dr Subhash Sharma,Dr Anurag Bijalwan Shri Guru Ram Rai Insitute of Medical and Health Sciences, Patel Nagar, Dehradun, India dralokvardhanmathur@yahoo.com
  • 2. • (Figure55
  • 3. • 35 year old male• Abdominal pain, vomiting, fever• On Examination- tachycardia, febrile, . Abdominal tenderness, reduced air entry leftiu base• Inv – leucocytosis, Blunting of Lt C/P angle, Mild free fluid in Abdomen• CT Abdomen-Diaphragmatic hernia with stomach and bowel loops in chest• Laparotomy –Diverticulitis with abscess with purulent fluid in peritoneal cavity- peritoneal lavage . Diaphragmatic hernia repaired in second stage
  • 4. Traumatic diaphragmatic injury - really an indicator of severe injury ? Dr Alok Vardhan Mathur, MS, Dr Manish Anand, DNB , Dr Madhukar Maletha, M Ch. (Ped Surg), Prof (Brig) Ramesh Kumar, MS. Department of Surgery, Shri Guru Ram Rai Institute of Medical and Health Sciences, Patel Nagar, Dehradun 248001 Introduction Discussion Background: Traumatic diaphragmatic injuries occur as a result of both blunt and •Look out for them, in the presence of haemo dynamic instability, with abdominal penetrating Trauma . Optimal treatment consists of repair through an abdominal pain, intestinal obstruction, pneumo-pericarditis, tension feco-pneumothorax , even approach with adequate attention to associated injuries. Most deaths in such with hematemeisis and malena . patients are not the result of the diaphragmatic injury itself, instead they are often •More frequent in males with blunt high velocity trauma, and on the left side related to the associated injuries. •X Ray signs: Collar sign, Diaphragmatic elevation, NG in thorax CT signs : Injury visualized, intra thoracic herniation , contrast extravasation , Methods collar sign, intra thoracic displacement of liver and spleen with spleenic vein thrombosis, large right diaphragmatic rupture with herniation of liver, gall bladder, Case 1: A 35 year female, with high velocity RTA, poly trauma, head injury, lower right kidney, ureter and renal vein limb fractures, pelvic fracture ,on ventilatory support, is referred to surgery, CXR •FAST scan : Reduced diaphragmatic movement on same side and CT are shown below. On laparotomy, a 10 cm rent in diaphragm, with herniating •A high index of suspicion, together with the knowledge of the mechanism of trauma, viable stomach and bowel loops, is repaired, she makes an uneventful recovery - is the key factor for the correct diagnosis[2]. GCS score improves only gradually -Discharged from neurosurgery about 35 days • Incorrect interpretation of the x ray or only intermittent later. •hernial symptoms are frequent reasons for incorrect diagnosis[3] •Right sided ruptures - high mortality and morbidity ,less likely than left sided tears •Mortality rates of 5 to 50% (higher when strangulation of herniating loops) • Meticulous per op examination of the diaphragm essential •Upto 30% present late [1] (Cause: delayed rupture of a devitalised diaphragmatic muscle, often precipitated by extubation) Conclusions: A careful search for these injuries is warranted in poly trauma patients, as up to 1.6% of these patients may have such injuries. They are commoner in males Conclusions and on the left side. Their presentation may be silent or related to the cardio respiratory effects that they may cause. They should always be repaired to avoid long term complications resulting from strangulation of herniating bowel loops. Laparoscopy is being used increasingly to determine diaphragmatic integrity. Patients with isolated diaphragmatic injuries tend to recover without long-term disability Case 2: 35 year old male - RTA victim – CXRPA shows blunt left CP Angle - ICD drains bilious fluid –Laparotomy reveals 5cm tear in left diaphragm with small bowel injury –diaphragm repaired with interrupted prolene sutures–post op develops intrabdominal collection-discharged on POD 16 References Case 3: 12 year old boy – 1. Pappas-Gogos G, Karfis E, Kakadellis J, Tsimoyiannis EC. Intrathoracic cancer of the RTA victim with respiratory splenic flexure. Hernia. 2007;11:257–259. doi: 10.1007/s10029-006-0182-3. [PubMed] distress and shock- CXR Results 2. Mintz Y, Easter DW, Izhar U, Edden Y, Talamini MA, Rivkind AI. Minimally invasive shown , on laparotomy, procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct viable stomach, spleen and diagnosis in selected patients. Am Surg. 2007;73:388–392. [PubMed small bowel found in chest – 3. DeBlasio R, Maione P, Avallone U, Rossi M, Pigna F, Napolitano C. Late posttraumatic diaphragmatic rent is repaired diaphragmatic hernia. A clinical case report. Minerva Chir. 1994;49:481–487. with interrupted vicryl - [PubMed] discharged on POD 8.TEMPLATE DESIGN © 2008www.PosterPresentations.com
  • 5. • Blunt and penetrating trauma.• They are often associated with significant associated injuries• Recognized by fluid in the CP angle, lower lobe collapse, elevated hemidiaphragm or by bowel loops in the chest.• Up to 70% of cases may be missed on chest radiographs and they may be associated with significant associated injuries which may by themselves be fatal.• CT scan and MRI may play and important role in diagnosis.• Stress the need of a high index of suspicion.• Optimal treatment consists of repair through an abdominal approach with adequate attention to associated injuries.• Most deaths in such patients are not the result of the diaphragmatic injury instead they are related to the associated injury.
  • 6. Clinical presentation Respiratory distress Decrease breath sounds on affected side Palpation of abdominal contents on insertion of chest tube or drainage of bowel contents in ICD Bowel sounds in chest Paradoxical abdominal movement on respiration Diffuse abdominal pain Hemodynamic or respiratory instability Intestinal obstruction Asymptomatic Low oxygen saturation
  • 7. Associated injuries• Polytrauma – head injuries, limb and pelvic fractures.• Bowel perforation• Spinal trauma• Other iatrogenic trauma• Asymptomatic• Interval from trauma to repair- 12 hours to 10 years, one patients never underwent surgery
  • 8. Findings• Left sided in all patients• Small bowel, spleen, stomach, colon in chest• Strangulated small bowel in one patient• Head injury – cerebral contusions , spinal injury, vertebral body fracture• Suspected the hernia on the basis of CXRPA in all our patients , confirmation on basis of CT Scan• Surgery offered to all , one refused it.
  • 9. Results• Twelve cases• Dehradun- tertiary care center• Frequent after RTA, fall from height in hilly regions• Sudden increase in intra-abdominal pressure following a fall• Countre coup injuries- to explain spinal and head injuries• By themselves they can be treated with good results.• However the mortality and morbidity is often decided by the nature of associated injuries.• More in males, in high velocity injuries, left side
  • 10. Surgery• All repaired abdominally• Mesh used in one• Results of repair were good• Three needed post op ventiatory support• One pt- intraabdominal collection – treated conservatively• Associated injuries influenced the morbidity hospital stay.
  • 11.  A careful search for these injuries is warranted in polytrauma patients, and upto 1.6% of such patients may have such injuries. They are commoner in males On the left side(except in children where the rates are equal) Occur more frequently after blunt trauma especially after motor vehicle accidents. Their presentation may be silent or related to the cardiorespiratory effects that they may cause. Some of them may be discovererd during laparotomy. They should always be repaired to avoid long term complications resulting from strangulation of herniating bowel loops. Laparoscopy is being used increasingly to determine diaphragmatic integrity. The outcome is generally related to concomitant injuries. Reported mortality ranges from 5.5-51%. People with isolated diaphragmatic injuries tend to recover without long-term disability
  • 12. Take home message• Incidence in the foothills of the Himalayas may be higher than the plains- relation to climbing trees for animal fodder or falls from roads in hills onto trees or slopes• Every blunting of CP Angle in trauma pts must raise the possibility• Varied clinical spectrum.• Can be repaired by general surgeons themselves with good results• Associated injuries often influence the eventual outcome

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