Pericardio-diaphragmatic rupture (PDR) is an uncommon injury, most frequently caused by high-velocity trauma, that can pose a diagnostic challenge to surgeons. We report a case of blunt traumatic PDR in a 35-year-old male who did not have any associated visceral injury. There was a 10cm rent in the left hemidiaphagm extending medially to involve the pericardio-diaphragmatic junction with uninjured heart and uninjured other visceral organs in the chest or abdomen. The stomach was partially herniated into the thorax and was easily pulled out at laparotomy, revealing the cardiac apex at the medial edge of the ruptured diaphragm. The rent was repaired with interrupted silk sutures and a left-sided intercostal chest tube was put in, which was removed two days before the patient was discharged on the 7th postoperative day. There were no complaints on follow-up. Introduction Traumatic diaphragmatic rupture (TDR) occurs in 0-5% of patients with major blunt thoraco-abdominal trauma, in most of them on the left side, and an early correct diagnosis is made in less than half of the cases[1,2]. The incidence of additional injured viscera in TDR is about 90-95%[3]. Pericardio-diaphragmatic rupture (PDR) is an uncommon problem that poses a diagnostic challenge to surgeons. The incidence of PDR is between 0.2% and 3.3% of cases with TDR[ 4 ]. We report a rare case of traumatic PDR without any associated visceral injury . Case Report A 35-year-old male passenger underwent a road traffic accident and was brought to casualty, complaining of pain in the left upper abdomen. The patient was hemodynamically stable . Abdominal examination revealed abrasion over the left iliac region, mild diffuse tenderness, guarding without rigidity or rebound, with decreased bowel sounds. On chest examination, movements were decreased over the left chest and breath sounds were decreased in lower and mid lung zones. There was no obvious bony fracture or subcutaneous emphysema. Cardiac examination was normal with regular rate and rhythm and without any added sounds. Chest x-ray revealed an elevated left hemidiaphagm with a smooth contour and a well defined radiolucent shadow in the left chest above the diaphragm along with adjacent plate-like atelectasis (figure 1). CECT of the chest confirmed diaphragmatic rupture with partial herniation of stomach into left chest (figures 2 and 3). Abdominal CECT revealed a mild amount of free fluid without any hollow or solid visceral injury (figure 4). The patient was operated two hours after the trauma and a laparotomy was made. Intraoperative findings included about 100ml of blood-stained free fluid, a 10cm rent in the left hemidiaphagm (figure 5) extending medially to involve 2cm of the pericardio-diaphragmatic junction with uninjured heart and uninjured other visceral organs in the chest or abdomen. The partially herniated stomach was easily pulled out and the rupture was repaired with interrupted silk sutures. A left-sided intercostal chest tube drain was put in, which was removed two days before the patient was discharged on the seventh day. The patient had no complaints on follow-up.
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