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Pesch CMW, Janki S, Faraj D, Hueting WE. Laparoscopic repair of a traumatic diaphragmatic rupture. Int J Surg Case Rep 2024; 118:109644. [PMID: 38653171 PMCID: PMC11063495 DOI: 10.1016/j.ijscr.2024.109644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/03/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Traumatic diaphragmatic ruptures following blast injury or penetrating trauma rarely present themselves with chronic symptoms warranting elective surgery. CASE PRESENTATION We present the case of a 49-year-old man who survived a grenade explosion and experienced chronic chest pain. Considering the previous trauma, computed tomography imaging was performed and showed a left-sided traumatic diaphragmatic rupture ventral to the spleen, resulting in herniation of the transverse colon and omentum in the thoracic cavity. Metal shrapnel was located between the stomach and spleen, the suspected cause of the diaphragmatic hernia. The patient was eligible for minimal invasive laparoscopic surgery. CLINICAL DISCUSSION During surgery, a left diaphragmatic rupture and metal shrapnel on the right side of the rupture were found. The hernia was reduced and the metal shrapnel was removed, aiding in fully repositioning of the omentum and transversed colon. After which the left lower lung lobe was able to fully inflate. The rupture was closed using single V-lock sutures and strips of the Phasix mesh to reinforce the diaphragm repair with single ethibond sutures. No surgical or post-operative complications were observed and the patient did not experience any of his previous complaints. CONCLUSION In this case, laparoscopic repair of diaphragmatic rupture after penetrating trauma can be considered as an effective surgical approach.
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Affiliation(s)
- Cedric M W Pesch
- Groene Hart Ziekenhuis, Gouda, Netherlands; LUMC, Leiden, Netherlands.
| | - Shiromani Janki
- Groene Hart Ziekenhuis, Gouda, Netherlands; LUMC, Leiden, Netherlands
| | | | - Willem E Hueting
- Groene Hart Ziekenhuis, Gouda, Netherlands; Alrijne Ziekenhuis, Leiderdorp, Netherlands
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2
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Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2019; 85:1007-1015. [PMID: 29659472 DOI: 10.1097/ta.0000000000001930] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.
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Koo CW, Johnson TF, Gierada DS, White DB, Blackmon S, Matsumoto JM, Choe J, Allen MS, Levin DL, Kuzo RS. The breadth of the diaphragm: updates in embryogenesis and role of imaging. Br J Radiol 2018; 91:20170600. [PMID: 29485899 DOI: 10.1259/bjr.20170600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The diaphragm is an unique skeletal muscle separating the thoracic and abdominal cavities with a primary function of enabling respiration. When abnormal, whether by congenital or acquired means, the consequences for patients can be severe. Abnormalities that affect the diaphragm are often first detected on chest radiographs as an alteration in position or shape. Cross-sectional imaging studies, primarily CT and occasionally MRI, can depict structural defects, intrinsic and adjacent pathology in greater detail. Fluoroscopy is the primary radiologic means of evaluating diaphragmatic motion, though MRI and ultrasound also are capable of this function. This review provides an update on diaphragm embryogenesis and discusses current imaging of various abnormalities, including the emerging role of three-dimensional printing in planning surgical repair of diaphragmatic derangements.
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Affiliation(s)
- Chi Wan Koo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | | | - David S Gierada
- 2 Department of Radiology, Washington University School of Medicine, Mallinckrodt Institute of Radiology , St. Louis, MO , USA
| | - Darin B White
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Shanda Blackmon
- 3 Department of Thoracic Surgery, Mayo Clinic , Rochester, MN , USA
| | | | - Jooae Choe
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA.,4 Department of Radiology, Asan Medical Center , Seoul , South Korea
| | - Mark S Allen
- 3 Department of Thoracic Surgery, Mayo Clinic , Rochester, MN , USA
| | - David L Levin
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Ronald S Kuzo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
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4
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Goh BKP, Wong ASY, Tay KH, Hoe MNY. Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma. CAN J EMERG MED 2015; 6:277-80. [PMID: 17382006 DOI: 10.1017/s148180350000926x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTRupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.
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Affiliation(s)
- Brian K P Goh
- Department of General Surgery, Changi General Hospital, Singapore.
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Hirano ES, Silva VG, Bortoto JB, Barros RHDO, Caserta NMG, Fraga GP. Plain chest radiographs for the diagnosis of post-traumatic diaphragmatic hernia. Rev Col Bras Cir 2013; 39:280-5. [PMID: 22936226 DOI: 10.1590/s0100-69912012000400007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 01/21/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe changes in the radiographic examination of the chest in patients with post-traumatic diaphragmatic hernia (PTDH) confirmed intra-operatively. METHODS Between January 1990 and August 2008 45 patients with PTDH were treated. We analyzed demographic data, cause of injury, changes in chest radiography (CXR), extent and location of the diaphragmatic lesion and herniated organs. We described the radiographic findings most frequently identified by surgeons and radiologists. RESULTS CXR was performed on 32 patients, predominantly male (27 cases, 84.4%) and the mean age was 34 years. The most common cause of injury was blunt trauma (25 cases, 78.1%). Radiographic examination of the chest showed changes suggestive of PTDH in 26 cases (81.3%). During exploratory laparotomy, left PTDH was found in 28 cases (87.5%) and right in four (12.5%). The most frequently herniated organ was the stomach. CONCLUSION The study showed that CXR is very useful in the initial diagnostic approach to PTDH. The difficulty is that diaphragmatic injuries, particularly after penetrating trauma, may initially go unnoticed, and without changes in the CXR images, diagnosis is made difficult.
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Bhullar IS, Block EFJ. CT with Coronal Reconstruction Identifies Previously Missed Smaller Diaphragmatic Injuries after Blunt Trauma. Am Surg 2011. [DOI: 10.1177/000313481107700121] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diaphragmatic injuries (DIs) are difficult to diagnose and often go unrecognized after blunt trauma. We proposed that CT scan with coronal reconstruction (CTCR) improves the detection of small DIs missed by chest x-ray (CXR) and CT scan with axial views (CTAX). We performed a retrospective review at a Level I trauma center from 2001 to 2006 and identified 35 patients who underwent operative repair of DI after blunt trauma. The size of the DI and the radiographic test (CXR, CTAX, and CTCR) that identified the defect was compared. Results were analyzed using mean, Mann-Whitney U test, and Fisher exact test. Of the 35 DI repairs, nine were performed after CXR alone and 12 after identification by both a CXR and CTAX. There was no significant difference between the mean DI size identified by CXR with and without CTAX (10.6 vs 9.7, P = 0.88). The remaining 14 DIs were undetected by CXR and CTAX. Seven of these (before CTCR) were found during exploratory laparotomy and seven were identified by CTCR (4.6 cm vs 3.5 cm, P = 0.33). The mean DI size identified by CTCR was significantly smaller than that identified by CXR alone (4.6 cm vs 9.7 cm, P < 0.05) and by CXR and CTAX (4.6 cm vs 10.6 cm, P < 0.0005). CTCR improves the ability to detect smaller DI defects (4 to 8 cm) that were previously missed by CXR and CTAX. CTAX adds little to CXR alone for the diagnosis of large defects (greater than 8 cm).
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Affiliation(s)
- Indermeet S. Bhullar
- Department of Surgery, University of Florida School of Medicine, Jacksonville, Florida
| | - Ernest F. J. Block
- Trauma Division, Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
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Rashid F, Chakrabarty MM, Singh R, Iftikhar SY. A review on delayed presentation of diaphragmatic rupture. World J Emerg Surg 2009; 4:32. [PMID: 19698091 PMCID: PMC2739847 DOI: 10.1186/1749-7922-4-32] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 08/21/2009] [Indexed: 11/10/2022] Open
Abstract
Diaphragmatic rupture is a life-threatening condition. Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. A comprehensive literature search was performed using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". The diagnostic and management challenges encountered are discussed, together with strategies for dealing with them. We have focussed on mechanism of injury, duration, presentation and site of injury, visceral herniation, investigations and different approaches for repair. We intend to stress on the importance of delay in presentation of diaphragmatic rupture and to provide a review on the available investigations and treatment methods. The enclosed case report also emphasizes on the delayed presentation, diagnostic challenges and the advantages of laparoscopic repair of delayed diaphragmatic rupture.
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Affiliation(s)
- Farhan Rashid
- Division of GI Surgery, University of Nottingham, Graduate Entry Medical School, Uttoxeter Road, Derby, DE22 3DT, UK.
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9
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Survival Following Rectal Impalement through the Pelvic, Abdominal, and Thoracic Cavities: A Case Report. Case Rep Med 2009; 2009:361829. [PMID: 19718249 PMCID: PMC2729288 DOI: 10.1155/2009/361829] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 06/13/2009] [Indexed: 11/19/2022] Open
Abstract
Impalement injuries are a unique form of penetrating trauma and are typically associated with a fall onto the object (Steele, 2006). We present the case of a 45-year-old man who reportedly slipped in his bathtub and fell onto a broomstick. Radiographic examination revealed a slender mass extending from his rectum to the right side of his neck. A review of English literature suggests that this is the second reported case in the last 100 years describing the successful management of an impalement injury traversing the pelvic, abdominal, and thoracic cavities. The management of this case is described.
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10
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De Rezende Neto JB, Guimarães TN, Madureira JL, Drumond DAF, Leal JC, Rocha A, Oliveira RG, Rizoli SB. Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile. Injury 2009; 40:506-10. [PMID: 19342047 DOI: 10.1016/j.injury.2008.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 11/11/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent. PATIENTS AND METHODS We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury. RESULTS Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis. CONCLUSION Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.
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Affiliation(s)
- João Baptista De Rezende Neto
- Department of Surgery Universidade Federal de Minas Gerais and Hospital Universitario Risoleta Tolentino Neves, Brazil
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11
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Bodanapally UK, Shanmuganathan K, Mirvis SE, Sliker CW, Fleiter TR, Sarada K, Miller LA, Stein DM, Alexander M. MDCT diagnosis of penetrating diaphragm injury. Eur Radiol 2009; 19:1875-81. [PMID: 19333606 DOI: 10.1007/s00330-009-1367-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 01/17/2009] [Indexed: 10/21/2022]
Abstract
The purpose of the study was to determine the diagnostic sensitivity and specificity of multidetector CT (MDCT) in detection of diaphragmatic injury following penetrating trauma. Chest and abdominal CT examinations performed preoperatively in 136 patients after penetrating trauma to the torso with injury trajectory in close proximity to the diaphragm were reviewed by radiologists unaware of surgical findings. Signs associated with diaphragmatic injuries in penetrating trauma were noted. These signs were correlated with surgical diagnoses, and their sensitivity and specificity in assisting the diagnosis were calculated. CT confirmed diaphragmatic injury in 41 of 47 injuries (sensitivity, 87.2%), and an intact diaphragm in 71 of 98 patients (specificity, 72.4%). The overall accuracy of MDCT was 77%. The most accurate sign helping the diagnosis was contiguous injury on either side of the diaphragm in single-entry penetrating trauma (sensitivity, 88%; specificity, 82%). Thus MDCT has high sensitivity and good specificity in detecting penetrating diaphragmatic injuries.
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Affiliation(s)
- Uttam K Bodanapally
- Department of Diagnostic Radiology, University of Maryland School of Medicine, 22 S Greene St., Baltimore, MD 21201, USA
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12
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Mirvis SE, Shanmuganagthan K. Imaging hemidiaphragmatic injury. Eur Radiol 2007; 17:1411-21. [PMID: 17308925 DOI: 10.1007/s00330-006-0553-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Revised: 10/10/2006] [Accepted: 11/17/2006] [Indexed: 12/18/2022]
Abstract
The supine chest radiograph is the initial and most commonly performed imaging study to evaluate the thorax after trauma. Whenever the chest radiograph is equivocal or suspicious for acute diaphragmatic injury (DI), computed tomography (CT) is usually the next study of choice since it is both generally available and often used to examine other body regions in the patient after trauma. CT is usually diagnostic, particularly if supplemented by multiplanar reformation (MPR) obtained using thin-slice axial scanning and overlapping images for reformations. Magnetic resonance imaging (MRI) is potentially useful to assess the diaphragm if CT findings are indeterminate and the patient is stable enough to have the procedure. Simple T1-weighted spin-echo images in the sagittal and coronal orientation are usually sufficient to establish or exclude DI. This article reviews imaging modalities and strategies for diagnosing DI from blunt trauma.
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Affiliation(s)
- Stuart E Mirvis
- Department of Diagnostic Radiology and the Maryland Shock-Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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13
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Affiliation(s)
- Colin P Cantwell
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
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14
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Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 2005; 22:601-4. [PMID: 15666270 DOI: 10.1016/j.ajem.2004.08.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abdominal injury from significant blunt trauma can include injury to bowel, kidneys, liver, and spleen. In approximately 5% of all injuries one of the diaphragms is ruptured. Diaphragmatic rupture may not be easily detected and this can lead to significant morbidity and even mortality. Rupture may be suggested on chest X-ray film especially with abnormal nasogastric tube location but the accuracy of this method is modest only. Abdominal computed tomography is not accurate and magnetic resonance imaging, although very sensitive and specific, is not feasible in most trauma situations. Surgeons have often resorted to exploratory laparotomy or laparoscopy to make the diagnosis. Although not typically part of the basic Focused Abdominal Sonography for Trauma (FAST) examination, ultrasonographic diagnosis of diaphragmatic rupture is possible with little added time to the examination. We present 3 cases of diaphragmatic rupture discovered shortly after the patients' arrival, on initial trauma evaluation with the FAST. A discussion of previous literature and ultrasound technique for diagnosis follows the cases.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, Atlanta, GA 30912-4007, USA.
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15
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Abstract
Traumatic diaphragmatic injury (TDI) occurs in approximately 6% of patients after major blunt trauma to the abdomen. Detection of such injuries is often problematic because of nonspecific clinical signs and the presence of additional intra-abdominal injuries. As the use of nonsurgical management to treat solid organ injuries increases, helical computed tomography (CT) must play a much greater role in the detection of intra-abdominal injuries. Therefore, it is crucial that diaphragmatic injuries are not overlooked, as fewer will be diagnosed at exploratory laparotomy. This article reviews the recent advances in helical CT that are helpful in diagnosing TDI and addresses the selected application of magnetic resonance imaging.
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Affiliation(s)
- Karen L Killeen
- Department of Diagnostic Radiology and Maryland Shock-Trauma Center, University of Maryland Medical Center, Baltimore 21201, USA
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16
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Abstract
Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury. Chest radiographs are the initial and most commonly performed imaging study to evaluate the diaphragm after trauma. When chest radiography is indeterminate, spiral computed tomography (CT) with thin sections and reformatted images is the next study of choice, particularly because most hemodynamically stable patients with blunt diaphragm injury will require an admission CT examination to evaluate the extent and anatomical sites of coexisting thoracoabdominal injuries. Magnetic resonance imaging is used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT.
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Affiliation(s)
- K Shanmuganathan
- Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore 21201, USA.
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17
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Murray JA, Demetriades D, Asensio JA, Cornwell EE, Velmahos GC, Belzberg H, Berne TV. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998; 187:626-30. [PMID: 9849737 DOI: 10.1016/s1072-7515(98)00246-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury. STUDY DESIGN Patients with penetrating injuries to the left lower chest who were hemodynamically stable and without indications for a celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia. RESULTS One-hundred-ten patients (94 stab wounds, 16 gunshot wounds) were evaluated with laparoscopy. Twenty-six (24%) diaphragmatic injuries were identified (26% for stab wounds and 13% for gunshot wounds). Comparison of patients with diaphragmatic injuries with those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% versus 24%, NS). The incidence of diaphragmatic injuries in patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injuries in only 1 of 7 patients (14%). The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries (22%, 27%, and 22% respectively). CONCLUSIONS The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.
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Affiliation(s)
- J A Murray
- Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles 90033, USA
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18
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19
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Mueller CF, Pendarvis RW. Traumatic injury of the diaphragm: Report of seven cases and extensive literature review. Emerg Radiol 1994. [DOI: 10.1007/bf02614912] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Rupture of the diaphragm occurs in approximately 5 per cent of cases of severe blunt trauma to the trunk, and the mortality may be as high as 50 per cent. The diagnosis is important because of the high incidence of associated organ damage and complications of a missed injury. Successful diagnosis requires a high index of suspicion but can be made from the chest radiograph in 90 per cent of cases if visceral herniation has occurred. We present three cases of rupture of the diaphragm which highlight the frequent occurrence of a delayed or missed diagnosis.
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Affiliation(s)
- P R Maddox
- University Department of Surgery, University of Wales College of Medicine, Cardiff, UK
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21
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Beg MH, Ansari MM, Mansoor T, Reyazuddin. Bilateral traumatic rupture of the diaphragm. ANNALS OF TROPICAL PAEDIATRICS 1990; 10:383-5. [PMID: 1708967 DOI: 10.1080/02724936.1990.11747462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 3.5-year-old girl sustained compression injury leading to isolated bilateral diaphragmatic rupture with extensive herniation of abdominal viscera into the pleuropericardial cavities. Reduction of the hernia and repair of the defects were readily accomplished through a thoraco-abdominal approach with excellent outcome.
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Affiliation(s)
- M H Beg
- Department of General Surgery, J. N. Medical College, AMU, Aligarh, India
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22
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Landau O, Schachner A, Lerner MA, Hauptman E, Friedman M, Levy MJ. Pneumothorax due to delayed rupture of traumatic trans-diaphragmatic gastric hernia. Eur J Radiol 1990; 10:59-61. [PMID: 2311608 DOI: 10.1016/0720-048x(90)90089-t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- O Landau
- Department of Cardiothoracic Surgery, Beilinson Medical Center, Petah Tikva, Israel
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23
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Kearney PA, Rouhana SW, Burney RE. Blunt rupture of the diaphragm: mechanism, diagnosis, and treatment. Ann Emerg Med 1989; 18:1326-30. [PMID: 2589701 DOI: 10.1016/s0196-0644(89)80270-7] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In the absence of respiratory distress and massive visceral herniation, the diagnosis of blunt diaphragmatic disruption can be difficult. This is particularly true for diaphragmatic injuries confined to the right hemidiaphragm. Because diagnostic delay and strangulation are associated with notable increases in mortality and morbidity, it is important to identify the injury as early as possible. Victims of lateral impact motor vehicle collisions are more likely to experience rupture of the diaphragm than victims of frontal collisions. Occupants exposed to left lateral impacts are at greatest risk. The side of diaphragmatic rupture correlates with the direction of impact. The right hemidiaphragm is more resistant to rupture. Deformation shear is a more plausible mechanism for diaphragmatic rupture after lateral impacts. Knowledge of the mechanisms that produce this injury combined with information regarding the victim's seat position and direction of the impacting force should lead to a high index of clinical suspicion for diaphragmatic rupture. Chest radiography and diagnostic peritoneal lavage will establish the correct diagnosis in almost 90% of the patients with acute diaphragmatic disruption. Additional diagnostic studies are reserved for the remaining 10% of patients. Due to the pressure differential between abdomen and thorax, the natural history of these injuries is one of enlargement, and none can be expected to heal spontaneously. Once the diagnosis has been established, the treatment of every diaphragmatic disruption is surgical repair.
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Affiliation(s)
- P A Kearney
- Department of Surgery, University of Kentucky, Lexington
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24
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Abstract
From January 1985 to December 1987, 292 laparotomies were performed for injury in Riyadh Central Hospital. Of these, 15 cases were associated with diaphragmatic injuries (5.1 per cent). The diagnosis was missed in 5 cases (30 per cent) and was incidental (at laparotomy) in 3 cases (20 per cent). Therefore in about 50 per cent of the cases, the diagnosis was not made at the initial presentation. In this paper we stress the importance of maintaining a high degree of clinical suspicion in order not to miss traumatic diaphragmatic hernia in multiply injured patients.
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Affiliation(s)
- M I Sebayel
- King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
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25
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Abstract
This study involved 163 patients with penetrating injuries of the diaphragm (knife, 139; bullet, 24). Intra-abdominal injuries were present in 122 patients (75 per cent) and this resulted in early diagnosis and treatment of the associated diaphragmatic injury (mortality 3.2 per cent). In the remaining 41 patients (25 per cent) the injury was confined to the diaphragm, and the diagnosis was missed during the initial admission in 10 patients who returned at a later stage with diaphragmatic hernia. A diaphragmatic hernia was found in 24 cases (14.7 per cent). Fourteen of these were diagnosed during the initial admission (mortality 7.1 per cent) and the remaining ten were diagnosed during a subsequent admission (mortality 30 per cent). The initial chest radiograph was diagnostic of diaphragmatic injury in 13 per cent, abnormal but not diagnostic in 76 per cent, and completely normal in 11 per cent. The importance of early diagnosis in reducing mortality, morbidity and hospital stay is emphasized. A high index of suspicion, careful clinical examination, and serial chest radiographs remain the best way of making the diagnosis.
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Affiliation(s)
- D Demetriades
- Department of Surgery, Baragwanath Hospital, Parktown, Johannesburg, South Africa
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26
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Levy IG, Saadia R, Boffard KD. Right-sided diaphragmatic rupture with herniation of the kidney presenting as an uncontrolled haemothorax--a case report. Injury 1988; 19:293. [PMID: 3229853 DOI: 10.1016/0020-1383(88)90055-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- I G Levy
- Trauma Unit, Johannesburg Hospital, South Africa
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27
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Abstract
Rupture of the diaphragm is a potentially serious complication of blunt trauma which can easily be overlooked at the time of presentation. This review examines the incidence and pathogenesis of the injury and discusses diagnosis and management.
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Affiliation(s)
- C D Johnson
- Department of Surgery, Westminster Hospital, London, UK
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28
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Gastinne H, Venot J, Dupuy JP, Gay R. Unilateral diaphragmatic dysfunction in blunt chest trauma. Chest 1988; 93:518-21. [PMID: 3277805 DOI: 10.1378/chest.93.3.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
This study was undertaken to evaluate unilateral diaphragmatic dysfunction within ten days after blunt chest trauma. Thirty patients with unilateral chest injury, or predominantly one-sided injuries, were investigated in the supine position, under analgesia. Right and left hemidiaphragm displacement (DD) was measured, using digital subtraction radiography, during quiet and forced breathing. The diaphragmatic contribution to breathing was determined by rib cage and abdominal circumference measurement changes. In both breathing modes, DD of the injured side was lower than DD of the uninjured side (p less than 0.01, p less than 0.001). Six patients had complete diaphragmatic motionlessness. The inspired air volume due to diaphragmatic motion (Vab) was reduced when compared to normal subjects and Vab/VT ratio was always found to be less than 0.65. The degree of diaphragmatic dysfunction appeared related to injury location and is most severe in injuries of the lower chest which implies direct diaphragm muscle injury, although other mechanisms may be implicated. Diaphragmatic dysfunction can contribute to respiratory failure in these patients, and should be considered.
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Affiliation(s)
- H Gastinne
- Department of Intensive Care Medicine, Dupuytren Academic Hospital, Limoges, France
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29
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30
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Abstract
More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.4 years. Seven injuries were on the left side; one was on the right side. The mechanism of injury was equally divided between penetrating and blunt trauma. Chest roentgenographic abnormalities were seen in all patients. Visceral reduction and diaphragmatic repair, despite strangulation in four patients, was accomplished without mortality and with minimal morbidity. Delayed presentation of TDH is reviewed, emphasizing diagnostic features encountered in the emergency department (ED).
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Emergency Service, Hospital
- Hernia, Diaphragmatic, Traumatic/diagnosis
- Hernia, Diaphragmatic, Traumatic/diagnostic imaging
- Hernia, Diaphragmatic, Traumatic/surgery
- Humans
- Intestinal Obstruction/etiology
- Male
- Middle Aged
- Radiography, Thoracic
- Time Factors
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/diagnostic imaging
- Wounds, Nonpenetrating/surgery
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/diagnostic imaging
- Wounds, Penetrating/surgery
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31
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Ala-Kulju K, Verkkala K, Ketonen P, Harjola PT. Traumatic rupture of the right hemidiaphragm. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1986; 20:109-14. [PMID: 3738439 DOI: 10.3109/14017438609106485] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Sixteen cases of traumatic disruption of the right hemidiaphragm are presented. Six tears were treated in the acute post-trauma phase and ten were detected from late manifestations. The causal trauma was penetrating in 11 cases and blunt in five. Rupture of the right hemidiaphragm not uncommonly occurs without serious associated injuries. Bowel often herniates through such tears, unhindered by the liver, though the liver is the most commonly herniating organ. No recurrence of hernia was found after standard repair techniques (mean follow-up 5.2 years). Three of the 16 patients died, one from associated injury, one from strangulation of herniated bowel and one from postoperative myocardial infarction. To demonstrate diaphragmatic tearing and subsequent organ herniation, serial chest radiographs and computed tomography are useful, and exploratory laporotomy should be done without delay after penetrating injury to the trunk. The treatment of diaphragmatic tear is surgical, with better results from early than from late repair.
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32
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33
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Tarver RD, Godwin JD, Putman CE. The Diaphragm. Radiol Clin North Am 1984. [DOI: 10.1016/s0033-8389(22)01179-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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34
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Ordog GJ, Wasserberger J, Balasubramaniam S. Tension gastrothorax complicating post-traumatic rupture of the diaphragm. Am J Emerg Med 1984; 2:219-21. [PMID: 6518015 DOI: 10.1016/0735-6757(84)90008-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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35
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Hagman J, Iguchi R, Kinsey J, Maningas P, Dronen S. Diaphragmatic rupture following blunt trauma. Ann Emerg Med 1984; 13:49-52. [PMID: 6689856 DOI: 10.1016/s0196-0644(84)80384-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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36
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Robicsek F. Biochemical termination of sustained fibrillation occurring after artificially induced ischemic arrest. J Thorac Cardiovasc Surg 1984. [DOI: 10.1016/s0022-5223(19)37456-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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38
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39
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40
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41
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Abstract
Eighteen cases of rupture of the diaphragm caused by blunt trauma of the trunk were seen over a ten-year period. Nine patients died, all from associated injuries of two or more systems. The ruptured diaphragm did not seem to contribute significantly to the cause of death. An acceptable rate of diagnosis was achieved by simple methods and a moderate delay in diagnosis did not affect the outcome.
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Moore JB, Moore EE, Thompson JS. Abdominal injuries associated with penetrating trauma in the lower chest. Am J Surg 1980; 140:724-30. [PMID: 7457690 DOI: 10.1016/0002-9610(80)90104-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A 5 year experience of 248 patients with isolated penetrating lower chest injury was reviewed. Twenty-two (15 percent) of the stab wounds and 46 (46 percent) of the gunshot wounds caused associated intraabdominal injury. Among those taken to the operating room for laparotomy, physical examination proved misleading in 40 percent of the patients with stab wounds and 30 percent of those with gunshot wounds. The diagnostic accuracy of peritoneal lavage, used selectively, was 93 per cent for the patients with stab wounds and 90 percent for those with gunshot wounds. The morbidity was high in patients with combined injuries, with major complications occurring in 27 percent of those with stab wounds and 43 percent of those with gunshot wounds. Two thirds or more of these complications were thoracic. There was one death (4 percent) among the patients with thoracoabdominal stab wounds and six (13 percent) among those with gunshot wounds.
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44
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Abstract
Diaphragmatic rupture due to blunt trauma is rare in childhood. The possibility of such injury must be borne in mind whenever blunt abdominal and chest trauma is encountered. This paper reports a case of diaphragmatic rupture in a child with multiple injuries sustained in a road accident.
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46
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Abstract
Traumatic injury of the diaphragm is not an infrequent occurrence. With the rise in violence and increasing use of automobiles, more diaphragmetic injuries may be seen, especially in inner-city hospitals. Sixty-six cases from our institution within the last five years were reviewed. Of these there were 41 penetrating injuries and 23 secondary to blunt trauma. Two cases were surgically induced following a difficult decortication for pleuropulmonary tuberculosis. There were ten deaths (15 percent mortality). All deaths were related to the severity of associated injuries. In addition, we analyzed 307 patients with multiple injuries who were dead on arrival and were autopsied by the county medical examiners in a 24-month period. Of the 307 autopsied cases, 16 (5.2 percent) had ruptured diaphragms. Interestingly, all but one of these cases were associated with thoracic aortic injuries. Diagnoses of penetrating diaphragmatic injuries were made during exploration of other injuries. In blunt diaphragmatic rupture, a high index of suspicion in most important in the diagnosis. In 10 of 23 blunt injuries, visceral herniation was noted on initial x-ray films. In four, follow-up films several hours to a day later showed loops of bowel in the chest. In nine cases, there were no apparent visceral herniations on initial films, and in these, the diagnosis was made during surgery for other indications. The surgical approach to diaphragmatic injuries is individualized. Acute left-sided injuries are best approached through the abdomen. Acute right-sided injuries and all chronic injuries should be approached through the chest.
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48
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49
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Abstract
In patients with nonpenetrating thoracic trauma, the rib fractures and other chest wall lesions may distract the physician from dangerous internal injuries in the chest or abdomen which may not be noted unless looked for very carefully. Early vigorous correction of any ventilatory problem is essential, particularly if there is any evidence of impaired tissue perfusion. Shock is frequently due to extrathoracic injuries, particularly intraabdominal bleeding. The flail associated with multiple rib fractures may seem mild initially, but severe underlying pulponary contusion and/or associated extrathoracic injuries make early ventilatory assistance extremely important. Rupture of the thoracic aorta should be suspected in rapid deceleration injuries, but is often not considered unless there is widening of the superior mediastinum on hte chest x-ray. Aortography to confirm the aortic tear should be done if time permits, and early repair of the injury provides the best results.
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50
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Abstract
The suggestion that early exploratory operation be performed in all patients with stab wounds of the left lower chest in whom the diaphragm is likely to be injured is examined in detail. The incidence of stabs in this situation is reported on an analysis of 1,000 consecutive cases of stab wounds of the chest. Thirteen cases of diaphragmatic hernia as a long-term complication of stab wounds of the chest are discussed.
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