Diaphragmatic injury in trauma: an entity that may be unnoticed

Background: Traumatic diaphragmatic injuries are rare, but their incidence has escalated due to the increase in traffic accidents and cases of urban violence. This pathology can be unnoticed under many circumstances, so a high level of suspicion is required to establish an early diagnosis and to prevent life-threatening complications. Case presentation: A 43-year-old male patient who is found in public street presenting a generally poor condition, with stigmata of trauma in the right frontotemporal region, deformity in the right humerus, multiple excoriations caused by friction, presumed to have suffered a traffic accident. The thorax was found with no deformities, no bone crepitus, and no signs of breathing difficulty. Discusion and literature review: Based on the injury mechanism, diaphragmatic trauma can be classified as blunt and penetrating trauma, attributing approximately two-thirds of cases to penetrating trauma (gunshots, stab wounds) and one-third to blunt trauma (car accident). The injured diaphragm presents a solution of continuity whose healing does not occur spontaneously and in the course of its evolution, migration from the abdominal organs to the pleural cavity may occur. The initial study in patients with suspected diaphragmatic lesion is usually a chest X-ray with diagnostic sensitivity in left-sided lesions ranging from 27%-62%, and for right-sided lesions, it is 17%-33%. Suggestive findings of diaphragmatic lesion include the collar sign (compression of the herniated organ at the point of the diaphragmatic lesion), bowel loops within the chest, arcing shadows in the left hemithorax, and the presence of the gastric chamber in the chest. Computed tomography is the study of choice in the polytraumatized patient for the evaluation of abdominal and thoracic trauma, due to its high sensitivity and specificity in the diagnosis of associated lesions.背景：创伤性膈肌损伤（Traumatic diaphragmatic injuries）较为罕见，但随着交通事故与城市暴力事件的增多，其发病率呈上升趋势。该病症在诸多情境下易被漏诊，因此需保持高度警惕以实现早期诊断，进而预防危及生命的并发症。 病例报告：1例43岁男性患者于公共街道被发现，全身状况欠佳，右额颞部可见创伤痕迹，右侧肱骨畸形，存在多发摩擦致擦伤，推测曾遭遇交通事故。胸部检查未发现畸形、骨擦音及呼吸困难体征。 讨论与文献复习：根据损伤机制，膈肌损伤可分为钝性创伤与穿透性创伤，约2/3的病例为穿透性创伤（枪击伤、刺伤），1/3为钝性创伤（车祸）。受损膈肌出现连续性中断，且无法自行愈合；随病情进展，腹腔脏器可疝入胸膜腔。疑似膈肌损伤患者的初始检查通常为胸部X线检查，其对左侧膈肌损伤的诊断敏感性为27%~62%，对右侧膈肌损伤的诊断敏感性为17%~33%。膈肌损伤的影像学提示征象包括：颈征（collar sign，疝出器官在膈肌损伤部位受压）、胸腔内肠袢、左侧半胸弧形阴影，以及胸腔内出现胃腔影。计算机断层扫描（Computed tomography，CT）因对合并损伤的诊断具有较高的敏感性与特异性，是多发伤患者胸腹创伤评估的首选检查手段。