Demographics:
18 years old, Male
Indication:
Trauma
Findings
Chest
- Left hemidiaphragmatic rupture with herniation of the stomach, splenic flexure of the colon, and superior tip of the spleen into the left hemithorax
- Compressive atelectasis of much of the left lower lobe
- Patchy groundglass opacities in the aerated portions of the left lung as well as layering dependently in the right lower lobe
- Trace left hemothorax
Abdomen/Pelvis
- Splenic hilar laceration measuring 13 mm in depth and additional 7 mm laceration along the inferior tip of the spleen
- Small volume perisplenic hemoperitoneum
- Trace free fluid layering in the anatomic pelvis
MSK
- Acute nondisplaced posterior left tenth rib fracture
- Small right upper anterior chest wall contusion at the level of the thoracic inlet
Diagnosis
Diaphragm rupture
Sample Report
Left hemidiaphragmatic rupture with herniation of the stomach, splenic flexure of the colon, and superior tip of the spleen into the left hemithorax.
Trace left hemothorax without pneumothorax.
Pulmonary contusion throughout the left lung with mild bilateral dependent groundglass opacities possibly relating to atelectasis and/or aspiration.
Two small splenic lacerations with adjacent small volume hemorrhage. No evidence of pseudoaneurysm or active bleeding.
Trace free fluid layering in the anatomic pelvis, which could relate to the splenic lacerations. However, occult bowel or mesenteric injury is not excluded.
Small upper right anterior chest wall contusion.
Discussion