Blunt aortic trauma, post-traumatic diaphragmatic hernia and pelvic fracture: Uncommon associations between injuries

Introduction:

High-energy blunt trauma is the main etiological mechanism of diaphragmatic hernias, pelvic fractures and traumatic aortic injuries. The force required to tear the pelvic ring associated with increased intra-abdominal pressure contributes to the rupture of the diaphragm. In addition, the application of anteroposterior impact can cause stretching of the aorta. Diaphragmatic hernia has association with pelvic fracture in 55% of cases and with aortic injury up to 10%.

Case history / Clinical findings / Investigation and Results / Diagnosis / Therapy and Progressions:

The reported case involves a 42-year-old man who suffered a rollover after a high velocity side collision between cars on the road. The patient presented a patent airway, RR 20, 120/80mmHg blood pressure, HR 88 bpm, GCS of 15 and negative FAST.

Whole body CT was performed due to trauma mechanism and hemodynamic stability, first identifying the traumatic aortic injury and pelvic fracture. The treatment of the aortic injury was endovascular using an endoprosthesis. The pelvic fracture had non-operative treatment and orthopedic rehabilitation. The patient was discharged after 12 days of hospitalization.

The diagnosis of diaphragmatic hernia was made in the 35th day post discharge, with the pacient presenting sub-occlusive symptoms. This delay was probably due to the difficulty in interpreting the CT image at the time of the primary survey, because of the presence of moderate hemothorax and pulmonary contusion in the lower lobe. After the conclusion of the diagnosis, laparoscopy correction was performed and the patient was discharged on the 4th day.

Comments:

Associations between aortic injury, post-traumatic diaphragmatic hernia and pelvic fracture with extraperitoneal bladder injury are rare and related to diagnostic difficulty, although the trauma mechanism involving high energy is common for these injuries. Furthermore, CT is the gold standard in diagnosing these injuries.

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