The pelvic fracture combined with diaphragmatic hernia is usually caused by a sudden increase in intra-abdominal pressure due to anterior and posterior violent compression, and is often accompanied by severe abdominal, pelvic and thoracic organ injuries, and the clinical symptoms are often masked by traumatic, hemorrhagic shock and other comorbidities, making it easy to miss the diagnosis.
Pelvic fractures are common in orthopedics, mostly caused by traffic accidents, smashes and crushes, and often combined with abdominal organ injuries, which are critical and complicated, but combined with traumatic diaphragmatic hernia is relatively rare.
The mechanism of diaphragmatic hernia complicated by pelvic fracture.
1, sudden increase in abdominal pressure: the fracture is caused by anterior and posterior violence, when injured, the abdominal cavity volume decreases sharply, abdominal pressure rises suddenly, the abdominal cavity wall resistance is not balanced, and the weakest area of the diaphragm is torn first. The diaphragm is composed of three parts: the sternum, the ribs and the lumbar part, with the muscle fibers concentrated towards the central tendon and ending at the central tendon. Between the starting points of the three parts, there is often a small triangular-shaped gap, which is the weak area and is a vulnerable site for diaphragmatic hernia.
2. The pressure difference between the thoracic and abdominal cavities causes the abdominal organs to move continuously into the thoracic cavity. The abdominal pressure is 2-10cmH2O (0.196-0.980KPa) when quiet, while the intrathoracic pressure is -5-10cmH2O (-0.490-0.980KPa), and the sudden increase in pressure difference can easily lead to the abdominal organs moving into the thoracic cavity. Diaphragmatic hernia is clinically more likely to occur on the left side because the liver has some shielding effect on the sudden increase in abdominal pressure.
The pathology of diaphragmatic hernia: the herniated organ in the thorax causes lung collapse due to occupancy, pulmonary ventilation is impaired, and in severe cases the mediastinum moves to the healthy side of the thorax, resulting in a decrease in cardiovascular blood flow and impaired circulation. The diaphragmatic rupture, i.e., strangulation of the hernia contents at the hernia ring, can lead to interruption of its blood circulation, impaction, strangulation, necrosis, perforation and pleural effusion, and eventually development of sepsis.
Diagnosis: Diaphragmatic hernia should be considered as a possibility in the presence of pelvic fractures with the following conditions.
1. persistent epigastric distension and pain that cannot be explained by other etiologies.
2. persistent epigastric pain, secondary to chest tightness, chest pain, and dyspnea that cannot be explained.
3.Thoracic drainage of large omentum or bile.
4, Bowel sounds are heard on chest auscultation with diminished or absent breath sounds.
5.TileB1 type pelvic fracture.
Common x-ray signs of diaphragmatic hernia include.
1. Loss of normal smooth contour line of the diaphragmatic surface or comprehensive deformation or absence, with abnormal shadows on the diaphragm connected to the shadow of subdiaphragmatic organs.
2. Mediastinal deviation.
3.The left hemithorax is filled with blood resulting in opacification, and sometimes air bubble shadow, spleen shadow, gastric bubble or gastrointestinal peristaltic shadow is visible.
4, Fluoroscopic gastric filling with dilute barium or iodine hydrography can suggest or establish the diagnosis.
Reasons for missed diagnosis.
1.Severe trauma or patient in shock, diaphragmatic hernia is easily overlooked by other symptoms.
The early symptoms of diaphragmatic hernia are often not obvious, and the clinical orthopedic surgeons are not aware of this disease, so it is easy to miss the diagnosis.
Diaphragmatic hernia can easily be accompanied by thoracic or abdominal injuries. If we are not vigilant and consider the possibility of diaphragmatic hernia, but do not perform in-depth and appropriate examination and analysis, we may easily mistake diaphragmatic hernia for other injuries.
Consequences of missed diagnosis and measures to improve the early diagnosis rate
Once a pelvic fracture combined with a traumatic diaphragmatic hernia is missed, the healing process is poor and the mortality rate is high (7), which should be taken seriously by orthopedic surgeons because of its serious consequences. When dealing with patients with multiple injuries mainly pelvic fractures, orthopedic surgeons should be especially alert to the possibility of TileB1 fractures combined with diaphragmatic hernia, examine the patients carefully, observe them continuously, assume the presence of diaphragmatic hernia first, and then exclude it carefully. The patient should be carefully examined and continuously observed, and the presence of diaphragmatic hernia should be assumed and then carefully excluded.
For patients with multiple injuries, mainly pelvic fractures, first of all, we should follow the principles of first aid for multiple injuries, treat first and then diagnose, and save lives while treating, and after resuscitation from shock and saving lives, we should conduct a careful systematic examination of the whole body in the order of CRASHYPLAN to clarify the diagnosis, and especially be alert to the presence of diaphragmatic hernia. We should pay great attention to the symptoms and signs of the chest and abdomen according to the mechanism of stress, closely observe various suspicious signs, repeated X-ray examinations if necessary, and strive for early diagnosis and early surgery.