Hospital: Hospital Virgen de la Luz (S E S C A M).
Nº: C2019-614
Aut@r o Autores: J. Gómez Hernández, R. Pampa Rodríguez, T. García Valverde, V. Jean-Pierre, M. Yasuda Gastello, S. Relanzón Molinero.
Presentación
80-year-old male who comes to Urgencies after an accidental fall with contusion in the left side. He presents a light dyspnea and thoracic pain, together with hypoxemia. Anemia is not detected. The initial thoracic radiography (TR) shows left pleural effusion as well as several ipsilateral rib fractures. The thoracic puncture confirms the presence of hemothorax, so a thoracostomy tube is placed. The patient evolves well after admission. However, a control TR shows an opacity along the inner margins of the left lateral ribs (figure 1A). Contrast-enhanced chest CT confirms the fracture of six left ribs and shows an adjacent biconvex fluid collection with inner displacement of a thin line of fat (“extrapleural fat sign”, EFS), consistent with an extrapleural hematoma (EH, figures 1B-D). Besides, it shows a left diaphragmatic discontinuity, with peritoneal fat herniation towards the thorax (figures 1B and 1D). Omentum is reduced through the defect and the DR is repaired via thoracotomy.
Discusión
TR is a fast and accessible imaging method. However, it has a low sensitivity, being the CT the gold standard. EFS can determine the extrapleural origin1 of the underlying cause of the pathology. The size and the shape of the EH (biconvex or non convex) suggest an arterial or venous origin1, conditioning the need of intervention or, as in this case, only clinical observation. With regard to diaphragmatic rupture (DR), about 19 radiological signs are described, which nomenclature is unclear. The latest revisions establish a sensitivity 61%–87%2 for diagnosis of diaphragmatic rupture, although there is variability. A high degree of suspicion is required as well as meticulous analysis for a correct diagnosis.
Conclusión
EH and hemothorax require different therapeutic management. The EFS is key to distinguishing such entities.The diagnosis of DR is complex. Multiplanar reconstructions with multidetector CT allow the detection with great sensitivity, even with small defects, as in this case.
Bibliografía
- Santamarina MG, Beddings I, Lermanda Holmgren GV, Opazo Sanchez H, Volpacchio MM. Multidetector CT for Evaluation of the Extrapleural Space, RadioGraphics. 2017, 37(5):1352–1370. - Panda A, Kumar A, Gamanagatti S, Patil A, Kumar S, Gupta A. Traumatic