Resolution of Chronic Shoulder Pain after Repair of a Posttraumatic Diaphragmatic Hernia: A 22-Year Delay in Diagnosis and Treatment

Abstract

Diagnosing traumatic diaphragmatic rupture (TDR) due to penetrating rib fractures is challenging because the lesions are often too small to be detected and may present years after injury. Patients with delays in diagnosis of TDR rarely present with orthopaedic-related complaints of pain. We report the case of a 52-year-old female who presented with chronic left shoulder pain following a motor vehicle accident (MVA). In addition to left-side lower rib fractures, she also sustained a left-sided splenic laceration, pneumothorax, and two-part upper humerus fracture. Fracture treatment was percutaneous pinning; the other injuries were treated nonoperatively. Her shoulder pain could not be attributed to shoulder or neck pathology. Twenty years after the MVA, she began experiencing episodes of left-sided abdominal pain and nausea. A CT scan obtained two years later revealed a diaphragm hernia, which was repaired laparoscopically. Unique aspects of this case include (1) presentation to an orthopaedic surgeon with a chief complaint of chronic shoulder pain; (2) at 22 years, this is the fourth longest case of a delay in diagnosis of TDR; and (3) the unique symptom of ipsilateral referred shoulder pain, which immediately improved after hernia repair.

Delayed hepatothorax: An unusual presentation case report

“…Our literature review revealed that most delayed traumatic diaphragmatic ruptures occurred within one year of the inciting event. Nonetheless, 17 cases were reported between 2 and 8 years after initial injury, 7 cases between 10 and 20 years, and 3 cases over 20 years, with the left side hernia being more common than right sided [2] . To the best of our knowledge, we present the fourth-longest delayed right-sided traumatic diaphragmatic rupture, presenting 13 years after the trauma incident [2] ( Table 1 ).…”

“…Traumatic diaphragmatic rupture is an uncommon lesion resulting from penetrating or blunt trauma to the abdomen or chest [1] . Up to 66% of traumatic diaphragmatic ruptures are undiagnosed during initial workup [2] . In cases of delayed presentation, the diagnosis becomes increasingly difficult over time due to a reduced index of suspicion [3] .…”

Treatment of Chronic Traumatic Diaphragmatic Hernia Based on Laparoscopic Repair: Experiences From 23 Cases

“…Abdominal organs herniated into the chest cavity would lead to clinical symptoms of different systems including chest symptoms (e.g., chest pain, tightness, shortness of breath, and dyspnea), abdominal symptoms (e.g., abdominal pain, nausea, vomiting, stop flatus and defecation, and other manifestations of intestinal obstruction, acid reflux, and belching), as well as the symptoms (e.g., chronic anemia). In cases of strangulation and necrosis in herniate organs, there might be signs of peritonitis, which is a great threat to the life of patients (4,5).…”

“…Diaphragmatic hernia patients with no spontaneous remission are suggested to undergo surgery upon diagnosis (4,6,7). To date, its treatment is highly relied on transthoracic, transabdominal and thoracoabdominal approaches (4,5,8,9). However, there are disputes on the efficiency of these treatment options.…”

Difficulties in diagnosing a rupture of the left dome of the diaphragm

“…Некроз стенки полых органов, ущемленных в грыжевых воротах, проявляется острой клинической картиной. При отсутствии ущемления с некрозом стенки полого органа проявлений может не быть [3,4]. Актуальным остается вопрос доступа -торакотомия или лапаротомия [5]?…”