ECR 2014 / C-2381
“A Stab in the Dark” – Review of multidetector CT imaging findings in penetrating diaphragmatic injury and correlation with clinical outcome. A UK Level 1 Trauma Centre Perspective.
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open license. Please read the
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Type:
Educational Exhibit
Keywords:
Trauma, Abdomen, Emergency, CT, Education, Acute
Authors:
S. E. West, T. Campion, S. G. Cross, S. Javed, R. Akhtar ; London/UK
DOI:
10.1594/ecr2014/C-2381
Findings and procedure details
Methods:
- Level 1 UK Trauma centre
- Manual search through trauma database since April 2007 to Nov 2013
- All CT’s were reported by a Senior Radiology registrar and approved by a Consultant.
- 66 patients admitted with penetrating abdominal injury and subsequently taken to theatre during this time
- Of the 65 patients,
20 patients did not have pre-operative CT,
4 died before they could have a CT,
and 8 did not have surgery post injury (other form of treatment,
conservative,
endoscopy etc.),
- 33 patient had a pre-operative CT, 19 of which did not pick up a diaphragmatic injury.
Of these 19 patients,
16 subsequently had surgery which confirmed diaphragmatic injury which was missed on CT.
- 14 patients of the 33 who had a pre-operative CT picked up a diaphragmatic injury,
all of which were accurately confirmed in surgery.
Results:
Surgical confirmation
|
CT did not report diaphragm injury
|
CT reported diaphragm injury
|
Total
|
Diaphragmatic injury present
|
16
|
14
|
30
|
Diaphragmatic injury not present
|
3
|
0
|
3
|
Total
|
19
|
14
|
33
|
Percentage correlation of CT with surgery
|
15.8%
|
100%
|
|
- The results indicate that when there is a diaphragmatic injury seen by the radiologists,
there is 100% correlation with the findings at post-CT surgery.
- However,
if a post trauma CT reports no diaphragmatic injury,
there is only 15.8% correlation with the findings at surgery,
and thus nearly 85% of all diaphragmatic injuries are being missed on CT scans.
Imaging Examples:
Case 1:
- See figure 2
- 28 year old man stabbed left upper quadrant
- Defect seen in the left hemi diaphragm demonstrated by the discontinuation
Case 2:
- See figure 3
- 25 year old,
stabbed on the left side
- Haemothorax
- Splenic laceration
- Injury on both sides of the diaphragm implies diaphagramatic injury
Case 3:
- See figure 4
- 18 year old with gunshot wound to the right side of the chest
- Shattered rib adjacent to liver
- Liver laceration
- Implied injury to diaphragm over the liver in the area of the entry wound
Case 4:
- See figure 5
- Trajectory of stabbing can be seen through subcutaneous fat,
under posterior left rib and into spleen
- splenic laceration with associated peri-splenic fluid
- Localised thickening of diaphragm with diaphragmatic defect
Case 5:
- See figure 6
- 31 year old,
Stabbing
- Haematoma seen within the subcutaneous tissue within anterior abdominal wall
- Intraperitoneal haematoma with implied injury to the central diaphragm was surgically confirmed
Case 6:
- See figure 7
- Haemathorax with splenic laceration post stabbing
- Injury above and below the diaphragm knife implies the knife must have traversed the left hemi-diaphragm causing injury
Case 7:
- See figure 8
- Herniation of loop of large bowel and omental fat through diaphragmatic defect
Case 8:
- See figure 9
- Hour glass appearance of the stomach in keeping with traumatic diaphragmatic rupture and gastric herniation