Submited on: 16 Nov 2010 07:16:37 AM GMT
Published on: 16 Nov 2010 06:15:16 PM GMT
 

1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? Yes
3 Is this a new and original contribution? No
4 Does this paper exemplify an awareness of other research on the topic? Yes
5 Are structure and length satisfactory? No
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? Yes
7 Can you suggest any reductions in the paper, or deletions of parts? Yes
8 Is the quality of the diction satisfactory? No
9 Are the illustrations and tables necessary and acceptable? No
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? Yes
  • Other Comments:

    Title

    Title is confusing and a more appropriate title should be; A Rare Case of Isolated Diaphragmatic Rupture following Blunt Abdominal Trauma

     

    Introduction

    Traumatic Diaphragmatic Rupture (TDR) – Use upper case where highlighted in red

    Motor Vehicle Accident (MVA) – Upper case where highlighted in red

    Similarly adjust for BTDR

    Is the incidence of 0.8% - 1.6% in relation to blunt trauma of abdomen or chest?  Clarify.

    What are the typical symptoms’ alluded to with regard to diagnosis of BTDR?

    Do away with the short sentence ‘An isolated BTDR is rare’ and introduce the word ‘rare’ higher up the segment as indicated in my adjustment below.

     

    Here is my suggestion as to how the article should generally be revised;

     

    Introduction

    Traumatic Diaphragmatic Rupture (TDR) is a recognized consequence of high velocity blunt trauma to the abdomen usually as a result of Motor Vehicle Accident (MVA) and occasionally by penetrating thoraco-abdominal trauma. Blunt Traumatic Diaphragmatic Rupture (BTDR) is a rare life threatening condition with an incidence of 0.8 – 1.6% in blunt abdominal trauma [1-3]. The diagnosis is often delayed due to the absence of characteristic signs and symptoms [4]. We present a case of isolated blunt traumatic rupture and review of literature.

     

    Case report

    A 24 year old man presented to the emergency department after sustaining injury in a road traffic accident. On examination, he was alert but dyspnoeic and the breath sounds in the left side of the chest were reduced. He had mild bruising of the anterior part of the chest and the upper abdomen. Initial chest X-ray showed haziness in the left hemi-thorax with doubtful presence of bowel loops [Figure 1]. We confirmed the presence of the diaphragmatic rupture with barium meal X-rays [Figure 2]. The patient was immediately taken for emergency laparotomy during which the diaphragmatic rupture was repaired.

     

    Please note that Figure 1 & 2 are the same and both have contrast – only Figure 2 should have contrast according to the text.

     

    Discussion

    Diaphragmatic rupture occurs in 6% of cases of penetrating or blunt trauma to the ?torso/chest and abdomen/abdomen. The major etiologic factors are blunt trauma sustained in motor vehicle accidents and penetrating trauma from gunshots or stabbing with a sharp object.

    The high morbidity and mortality in these cases is as a result of difficulties in making the diagnosis. When diaphragmatic injuries are not recognized in the acute phase following the trauma, the affected structures may become strangulated with resultant increase in mortality from 20 – 80%.

    During severe abdominal trauma, a tenfold increase in intra-abdominal pressure can occur, transmitting a sudden blow of kinetic energy through the domes of the hemi-diaphragm. Isolated BTDR is rare and might be followed by a period of weeks or months without any signs or symptoms [2,5]. Most BTDR are located on the left side in the musculo tendinous intersection [1,3,4]. Right BTDR are rarely described and less frequent [6]. Herniation of colon, small bowel or liver may occur with resultant ileus, necrosis or perforation [4,7].

    Irrespective of the mechanism of injury, the early recognition of an occult TDR is usually dependent on a high index of suspicion. A combination of any of the following signs and symptoms should arouse suspicion of TDR and prompt further diagnostic tests:  History of pericostal injury, fracture pelvis or lumbar spine reflecting a major compression of the torso, dyspnea, pain in the lower chest or abdomen, dullness or a tympanitic note on auscultation of the lower chest, mediastinal shift and bowel sounds in the chest.

    When the clinical and chest X-ray findings suggest a diaphragmatic injury, appropriate contrast GI studies may be helpful conclusive diagnostic tools for precise diagnosis. Although UltraSonoGraphy (USG) is a noninvasive modality, a conclusive diagnosis may be difficult particularly in patients without herniation [8]. Computed Tomography (CT) is a reliable diagnostic tool in cases with suspected diaphragmatic injury long after the traumatic event [9,10].

     

    Conclusion

    Although TDR is a rare injury, it must be suspected in all trauma patients. It’s prompt identification depends on a high index of suspicion and careful attention to physical and chest X-ray findings initially. A high index of suspicion makes diagnosis less difficult. Chest/abdominal X-ray and in particular cases, CT and USG improve the accuracy of diagnosis. If surgery is prompt thereafter, morbidity and mortality is lowered in patients with TDR.

     

    References

    The listing is inconsistent and there are a number of errors/issues which need to be addressed. I have highlighted these in the accompanying document.

    I noted that 50% of the references were fairly recent (2009) which is a good thing.

    I wonder if Webmedcentral has guidelines for listing references; if at all there are guidelines, I suggest that we follow them and if not you should use the format used by most journals. The authors’ names for example are usually listed with the surname first followed by the initials.

     

     

     

     

     

     

    Dr. Joseph K.Wanjeri

    Plastic & Reconstructive Surgeon

    Lecturer – School of Medicine, University of Nairobi – KENYA

    Email:   onejerry@yahoo.com,   joseph.wanjeri@uonbi.ac.ke

     

  • Competing interests:
    None
  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    I recall a case which I handled as a General Surgeon reffered from another hospital following a Road Traffic Accident and blunt trauma to the chest. The diagnosis of ruptured diaphragm had been missed at the reffering hospital and the patient might have died if I had not performed a thorough physical examination and requested for a chest X-ray.

  • How to cite:  Wanjeri J K.A Rare Case Of Isolated Blunt Traumatic Diaphragmatic Rupture[Review of the article 'A Rare Case Of Isolated Blunt Traumatic Diaphragmatic Rupture ' by Selvaraju K].WebmedCentral 2011;2(5):WMCRW00723
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1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? Yes
3 Is this a new and original contribution? No
4 Does this paper exemplify an awareness of other research on the topic? Yes
5 Are structure and length satisfactory? Yes
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? Yes
7 Can you suggest any reductions in the paper, or deletions of parts? Yes
8 Is the quality of the diction satisfactory? No
9 Are the illustrations and tables necessary and acceptable? No
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? No
  • Other Comments:

    Title

    Title is confusing and a more appropriate title should be; A Rare Case of Isolated Diaphragmatic Rupture following Blunt Abdominal Trauma

     

    Introduction

    Traumatic Diaphragmatic Rupture (TDR) – Use upper case where highlighted in red

    Motor Vehicle Accident (MVA) – Upper case where highlighted in red

    Similarly adjust for BTDR

    Is the incidence of 0.8% - 1.6% in relation to blunt trauma of abdomen or chest?  Clarify.

    What are the typical symptoms’ alluded to with regard to diagnosis of BTDR?

    Do away with the short sentence ‘An isolated BTDR is rare’ and introduce the word ‘rare’ higher up the segment as indicated in my adjustment below.

     

    Here is my suggestion as to how the article should generally be revised;

     

    Introduction

    Traumatic Diaphragmatic Rupture (TDR) is a recognized consequence of high velocity blunt trauma to the abdomen usually as a result of Motor Vehicle Accident (MVA) and occasionally by penetrating thoraco-abdominal trauma. Blunt Traumatic Diaphragmatic Rupture (BTDR) is a rare life threatening condition with an incidence of 0.8 – 1.6% in blunt abdominal trauma [1-3]. The diagnosis is often delayed due to the absence of characteristic signs and symptoms [4]. We present a case of isolated blunt traumatic rupture and review of literature.

     

    Case report

    A 24 year old man presented to the emergency department after sustaining injury in a road traffic accident. On examination, he was alert but dyspnoeic and the breath sounds in the left side of the chest were reduced. He had mild bruising of the anterior part of the chest and the upper abdomen. Initial chest X-ray showed haziness in the left hemi-thorax with doubtful presence of bowel loops [Figure 1]. We confirmed the presence of the diaphragmatic rupture with barium meal X-rays [Figure 2]. The patient was immediately taken for emergency laparotomy during which the diaphragmatic rupture was repaired.

     

    Discussion

    Diaphragmatic rupture occurs in 6% of cases of penetrating or blunt trauma to the ?torso/chest and abdomen/abdomen. The major etiologic factors are blunt trauma sustained in motor vehicle accidents and penetrating trauma from gunshots or stabbing with a sharp object.

    The high morbidity and mortality in these cases is as a result of difficulties in making the diagnosis. When diaphragmatic injuries are not recognized in the acute phase following the trauma, the affected structures may become strangulated with resultant increase in mortality from 20 – 80%.

    During severe abdominal trauma, a tenfold increase in intra-abdominal pressure can occur, transmitting a sudden blow of kinetic energy through the domes of the hemi-diaphragm. Isolated BTDR is rare and might be followed by a period of weeks or months without any signs or symptoms [2,5]. Most BTDR are located on the left side in the musculo tendinous intersection [1,3,4]. Right BTDR are rarely described and less frequent [6]. Herniation of colon, small bowel or liver may occur with resultant ileus, necrosis or perforation [4,7].

    Irrespective of the mechanism of injury, the early recognition of an occult TDR is usually dependent on a high index of suspicion. A combination of any of the following signs and symptoms should arouse suspicion of TDR and prompt further diagnostic tests:  History of pericostal injury, fracture pelvis or lumbar spine reflecting a major compression of the torso, dyspnea, pain in the lower chest or abdomen, dullness or a tympanitic note on auscultation of the lower chest, mediastinal shift and bowel sounds in the chest.

    When the clinical and chest X-ray findings suggest a diaphragmatic injury, appropriate contrast GI studies may be helpful conclusive diagnostic tools for precise diagnosis. Although UltraSonoGraphy (USG) is a noninvasive modality, a conclusive diagnosis may be difficult particularly in patients without herniation [8]. Computed Tomography (CT) is a reliable diagnostic tool in cases with suspected diaphragmatic injury long after the traumatic event [9,10].

     

    Conclusion

    Although TDR is a rare injury, it must be suspected in all trauma patients. It’s prompt identification depends on a high index of suspicion and careful attention to physical and chest X-ray findings initially. A high index of suspicion makes diagnosis less difficult. Chest/abdominal X-ray and in particular cases, CT and USG improve the accuracy of diagnosis. If surgery is prompt thereafter, morbidity and mortality is lowered in patients with TDR.

     

    References

    The listing is inconsistent and there are a number of errors/issues which need to be addressed. I have highlighted these in the accompanying document.

    I noted that 50% of the references were fairly recent (2009) which is a good thing.

    I wonder if Webmedcentral has guidelines for listing references; if at all there are guidelines, I suggest that we follow them and if not you should use the format used by most journals. The authors’ names for example are usually listed with the surname first followed by the initials.

     

     

     

     

     

     

    Dr. Joseph K.Wanjeri

    Plastic & Reconstructive Surgeon

    Lecturer – School of Medicine, University of Nairobi – KENYA

    Email:   onejerry@yahoo.com,   joseph.wanjeri@uonbi.ac.ke

  • Competing interests:
    No
  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    I handled one case of Blunt Traumatic Diaphragmatic Rupture years back while preactising as a General Surgeon. The diagnosis had been missed at the reffering hospital and the patient could well have died if my clinical examination was not thorough and if the chest X-ray had not been ordered. The recovery was fast following repair of the ruptured diaphragm.

  • How to cite:  Wanjeri J K.A Rare Case Of Isolated Blunt Traumatic Diapgragmatic Rupture[Review of the article 'A Rare Case Of Isolated Blunt Traumatic Diaphragmatic Rupture ' by Selvaraju K].WebmedCentral 2011;2(5):WMCRW00721
1 2 3 4 5 6 7 8 9
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