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CASE SCENARIO

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A 22-year-old man was brought to the emergency department (ED) after a motor vehicle accident. The patient was entrapped and restrained in the passenger seat of a car that had been impacted on the passenger’s side by a truck.

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On arrival to the emergency room his airway was patent, and he was immobilized with a rigid cervical collar and backboard. His respiratory rate was 20 breaths per minute with decreased breath sounds at the right base, and his oxygen saturation was 97% on 15 L oxygen through reservoir mask. His heart rate was 96 beats per minute and his blood pressure 139/91 mm Hg. He had a Glasgow Coma Scale (GCS) score of 15, and there was no loss of consciousness.

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The remainder of his physical examination was significant for cervical spine tenderness, right-sided ecchymosis of the torso with ipsilateral pain, mild shortness of breath, and tenderness over the right 8th, 9th, and 10th ribs. He complained of diffuse abdominal discomfort and had mild tenderness to palpation of the right upper abdominal quadrant. He had a right arm deformity, but neurovascular examination was symmetrical to the contralateral limb. The remainder of the examination was unremarkable. His chest x-ray demonstrated right-side rib fractures, and a small right hemothorax with opacity in the right lower lung field. His focused assessment with sonography for trauma (FAST) scan was positive for perihepatic and perisplenic fluid. A right chest tube was placed that returned 300 cc of blood.

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Following this, the patient underwent contrast-enhanced computed tomography (CT) scan evaluation remarkable for fractures of the right 8th, 9th, and 10th ribs; grade III liver laceration with hemoperitoneum; and rupture of the right hemidiaphragm. X-rays of the right upper arm revealed a midshaft humerus fracture.

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A decision was made to take the patient to the operating room for exploratory laparotomy given the diaphragmatic injury. A 7-cm rupture of the right hemidiaphragm and the liver laceration were confirmed and repaired. Open reduction and internal fixation of the upper arm fracture took place under the same anesthesia.

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Postoperative course was unremarkable and he was discharged in good condition.

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EPIDEMIOLOGY

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The incidence of diaphragmatic injury (DI) after trauma ranges from 0.8% to 8% after blunt trauma and 10% to 15% after penetrating trauma.1, 2, 3, 4, and 5 Penetrating trauma is the leading cause (63%–73%) of all traumatic DI, with an incidence of 30% to 42% among patients with thoracoabdominal wounds.5,6 For blunt trauma, approximately 90% of diaphragmatic ruptures occur after motor vehicle accidents, with falls and crush injury constituting the remainder.7,8 Nearly two-thirds of DI following blunt trauma occurs in the left hemidiaphragm, although right diaphragmatic rupture may be underdiagnosed.9,10 Bilateral hemidiaphragm injuries are reported in 2% to 6% of patients.11,12...

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