Rupture of the diaphragm in blunt injuries of the trunk

Traumatic rupture of the diaphragm: a difficult diagnosis

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.

Successful transthoracic repair of a ruptured spleen

Images

Acquired hernias of the diaphragm

We present our experience over five and a half years of acquired hernias of the diaphragm. Each case represents a different presentation of this condition, which may follow blunt or penetrating trauma or iatrogenic injury. Diaphragmatic hernia may present in the acute phase after injury but late presentation may occur after many years, with chronic abdominal or respiratory symptoms, or with acute intestinal obstruction. The problems in diagnosis and management are discussed.

Blunt injuries of the diaphragm

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.

[Misdiagnosed rupture of the diaphragm following blunt thoracic-abdominal trauma]

The histories of 67 patients with a diaphragmatic rupture due to blunt trauma were reviewed in four hospitals. In 45 patients the diagnosis was made within 24 hours after the accident, in the other 22 patients the rupture was diagnosed in a later stage. In the first group there were much abdominal injuries and during emergency laparotomy for some other reasons in 29% of these cases the diaphragmatic rupture was found accidentally. Not recognizing a rupture in the acute phase and therefore delaying operation was caused by the fact that the initial chest X-ray was not thoroughly checked for signs of a diaphragmatic rupture. The reasons for operation in the "delayed" group were mainly typical abnormalities for diaphragmatic rupture of the chest X-rays and other investigations proving the diagnosis. Only in one patient the delay in diagnosis has led to a very serious complication: because of incarceration with gangrene of a part of the small bowel it was necessary to remove this part. The other 21 patients in the group where the diagnosis was initially missed did not suffer from any serious complication.

Volvulus of the stomach--an unusual cause of pulsus paradoxus

A patient with a strangulated diaphragmatic hernia presented as an emergency and was noted to have pulsus paradoxus. The mechanism of this physical sign, previously unrecorded in association with an intrathoracic hernia, is discussed.

Traumatic rupture of the diaphragm

This paper reviews 58 patients with traumatic rupture of the diaphragm treated at the Royal Adelaide Hospital during an 11-year period. The series appears to be the largest reported from one centre. The majority of cases resulted from blunt trauma to the trunk caused by motor vehicle accidents. More than half these patients sustained multiple injuries. A smaller group of patients had penetrating injuries to the diaphragm from gunshot or stab wounds. Clinical diagnosis of the ruptured diaphragm was seldom possible; an erect X-ray film of the chest was the best clue to diagnosis. In the acute phase, the injury was approached through laparotomy because of the need to exclude or treat other intra-abdominal injuries. Where diagnosis or treatment were delayed, thoracotomy was the approach of choice. Careful postoperative management, particularly of associated chest injuries, was the key to the low mortality achieved in this series.