Blunt traumatic diaphragmatic injury: A diagnostic enigma with potential surgical pitfalls

Traumatic Diaphragmatic Injuries at Medicolegal Autopsy: A 1-Year Prospective Study

INTRODUCTION

Traumatic diaphragmatic injuries (TDIs) are relatively rare. The forensic literature pertaining to TDIs consists mainly of case studies, suggesting little attention to these injuries during autopsies and research.

MATERIALS AND METHODS

This prospective study was conducted at the Ga-Rankuwa Forensic Pathology Services mortuary over a 1-year period. We included all cases who had a full medicolegal autopsy, as prescribed by the relevant South African legislation (Inquest Act 58 of 1959). All diaphragms were examined by a forensic medical practitioner performing the autopsy.

RESULTS

Nine hundred ninety-nine cases were analyzed; of these, 71 cases with TDIs were identified. The incidence of TDI was, therefore, determined to be 7.11%. A total of 60.56% involved the right hemidiaphragm, 19.72% the left hemidiaphragm, and 19.72% were present bilaterally. A total of 85.92% were present in men and 14.08% in women. Blunt force trauma comprised 33.80%, and penetrative trauma 61.97%. Most were associated with severe injuries. A total of 12.68% had organ herniation through the defects present.

CONCLUSIONS

Our study revealed that TDIs were more common than initially reported. The right side was more often involved in our study than in other studies. Diaphragmatic injuries were observed in 21.46% of all penetrative trauma cases received in a year.

Diaphragmatic Injuries among Severely Injured Patients (ISS ≥ 16)-An Indicator of Injury Pattern and Severity of Abdominal Trauma

Background and Objectives: Abdominal trauma among severely injured patients with an injury severity score (ISS) of 16 and above can lead to potentially life-threatening injuries that might need immediate surgical intervention. Traumatic injuries to the diaphragm (TID) are a challenging condition often accompanied by other injuries in the thoracoabdominal region. Materials and Methods: We retrospectively analyzed the occurrence and clinical course of TID among severely injured patients treated at our center between 2008 and 2019 and compared them to other groups of severely injured patients without TID. Results: Thirty-five patients with TID and a median ISS of 41 were treated in the period mentioned above. They were predominantly middle-aged men and mostly victims of blunt trauma as a consequence of motor vehicle accidents. A total of 70.6% had left-sided TID, and in 69.6%, the size of defect was larger than 10 cm. The diagnosis was made with computed tomography (CT) in 68.6% of the cases, while in 25.8%, it was made intraoperatively or delayed by a false-negative initial CT scan, and in 5.7%, an intraoperative diagnosis was made without preoperative CT imaging. Surgical repair was mostly conducted via laparotomy, performing a direct closure with continuous suture. A comparison to 191 patients that required laparotomy for abdominal injuries other than TID revealed significantly higher rates of concomitant injuries to several abdominal organs among patients suffering from TID. Compared to all other severely injured patients treated in the same period (n = 1377), patients suffering from TID had a significantly higher median ISS and a longer mean duration of hospital stay. Conclusions: Our findings show that TID can be seen as an indicator of particularly severe thoracoabdominal trauma that requires increased attention from the treatment team so as not to miss relevant concomitant injuries that require immediate intervention.

Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®

INTRODUCTION

Traumatic diaphragmatic rupture is a rare injury in the severely injured patient and is most commonly caused by blunt mechanisms. However, penetrating mechanisms can also dominate depending on regional and local factors. Traumatic diaphragmatic rupture is difficult to diagnose and can be missed by primary diagnostic procedures in the resuscitation room. Initially not life-threatening, diaphragmatic ruptures can cause severe sequelae in the patient's long-term course if untreated. The objective of this study was to assess the epidemiology, associated injuries, and outcome of traumatic diaphragmatic ruptures based on a multicenter registry-based analysis.

MATERIAL AND METHODS

Data from all patients enrolled in the TraumaRegister DGU® between 2009 and 2018 were retrospectively analyzed. That multicenter database collects data on prehospital, intra-hospital emergency, intensive care therapy, and discharge. Included were all patients with a Maximum Abbreviated Injury Scale (MAIS) score of 3 or above and patients with a MAIS score of 2 who died or were treated in the intensive care unit, for whom standard documentation forms had been completed and who had sustained a diaphragmatic rupture (AIS score of 3 or 4). The data has been analyzed using descriptive statistics and chi-square test or Mann-Whitney U test.

RESULTS

Of the 199,933 patients included in the study population, 687 patients (0.3%) had a diaphragmatic rupture. Of these, 71.9% were male. The mean patient age was 46.1 years. Blunt trauma accounted for 73.5% of the injuries. Primary diagnosis was established in the resuscitation room in 93.1% of the patients. Multislice helical computed tomography (MSCT) was performed in 82.7% of the cases. Rib fractures were detected in 60.7% of the patients with a diaphragmatic injury. Patients with diaphragmatic rupture had a higher mean Injury Severity Score (ISS) than patients without a diaphragmatic injury (32.9 vs. 18.6) and a higher mortality rate (13.2% vs. 9.0%).

CONCLUSIONS

In contrast to the literature, primary diagnostic procedures in the resuscitation room detected relevant diaphragmatic ruptures (AIS ≥ 3) in more than 90% of the patients in our study population. In addition, complex associated serial rib fractures are an important diagnostic indicator.

Unexpected Diaphragmatic Hernia Among Patients Undergoing Video-Assisted Thoracic Surgery for Internal Fixation of Rib Fractures

Traumatic blunt diaphragm injuries are a diagnostic challenge in trauma. They may be missed due to the increasing trend of non-operative management of patients. The purpose of this study was to review the rate of occult blunt diaphragm injuries in patients who underwent video assisted thoracic surgery (VATS) for rib fixation. This retrospective study included patients that received VATS as part of our institutional protocol for rib fracture management. This includes utilizing incentive spirometry, multimodal analgesia, and early consideration for VATS. Data was abstracted from the electronic medical record and included demographics, operative findings, and outcomes. Thirty patients received VATS per our rib fracture protocol. No patients had any identified diaphragm injury on pre-operative imaging. A concomitant diaphragm injury was identified in 20% (6/30) of the study population. All patients were alive at 30 days. For all patients, total hospital length of stay was 14.5 days, ICU length of stay was 8.9 days, and average ventilator days was 4.2 days. When comparing patients with and without concomitant diaphragm injuries, hospital length of stay was 16.8 days vs. 14.5 (P = 0.59), ICU length of stay was 11.8 days vs. 8.2 (P = 0.54), and ventilator days was 4.5 days vs. 4.2 (P = 0.93). This study revealed that 20% of patients undergoing VATS for rib fracture fixation had a concomitant diaphragm injury. This higher-than-expected prevalence suggests that groups of patients sustaining blunt trauma may have occult diaphragmatic injuries that are otherwise unidentified. This raises the need for improved diagnostic modalities to identify these injuries.

Comparisons of Trauma Outcomes and Injury Severity Score

Trauma is a global health problem and a leading cause of mortality. One of the major predictors of trauma mortality is the Injury Severity Score (ISS). Theoretically, as the ISS increases, the probability of survival decreases; ISS = 75 is considered to be not survivable. Studies have shown that some deaths are preventable and some potentially preventable. Hemorrhagic shock is a potentially preventable cause of trauma mortality. A retrospective database review was conducted of the Mississippi Trauma Registry and point-by-serial correlational analyses were conducted to determine the direction of any significant relations between blood product usage, traditional vital signs, and shock index. Pearson correlation, logistic regressions, and odds ratio calculation results revealed that shock index can signal impending hemorrhagic compromise better than traditional vital signs; thus, facilitating early intervention, specifically, as heart rate and shock index increase, the use of blood products increases, and as blood pressure increases, the use of blood products decreases. Independent t tests for shock index and ISS revealed significant differences in the means with relationship to the subgroups "Dead" and "Alive." Higher ISS were found to correlate with higher shock indices. Evaluation of ISS and survivability demonstrates that ISS = 75 is survivable and should not lead one to reflexively assume otherwise. A total mortality finding of only 1.58% (n = 2,010) was unexpected but very encouraging.

Unravelling the Mysteries of Traumatic Diaphragmatic Injury: An Up-to-Date Review

Traumatic diaphragmatic injury (TDI) is an underdiagnosed condition that has recently increased in prevalence due to its association with automobile collisions. The initial injury is often obscured by concurrent thoracic and abdominal injuries. Traumatic diaphragmatic injury itself is rarely lethal at initial presentation, however associated injuries and complications of untreated TDI such as herniation and strangulation of abdominal viscera have serious clinical consequences. There are 2 primary mechanisms of TDIs: penetrating TDI which tend to be smaller, more difficult to detect, and result in fewer complications; and blunt TDIs which are larger and have higher overall mortality due to associated injuries or delayed complications. The anatomy of thoracic and abdominal cavities distinguishes the epidemiology, pathophysiology, symptoms, treatment, and prognosis of right versus left TDI. Although there is no definitive radiologic sign for diagnosing TDI, many signs have been introduced in the literature and the concurrent presence of multiple signs increases the sensitivity of TDI detection. Conservative versus surgical management depends on mechanism of TDI, side, and most importantly the associated injuries.

Traumatic Diaphragmatic Rupture with Transthoracic Organ Herniation: A Case Report and Review of Literature

Patient: Female, 59-year-old

Final Diagnosis: Axillo-subclavian vessel injuries

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Surgery

Massive hemothorax due to two bleeding sources with minor injury mechanism: a case report

Background

Massive hemothorax resulting from a minor injury mechanism is considered to be rare particularly when the diaphragm is injured. We report a case of massive hemothorax with bleeding from the intercostal artery and diaphragmatic damage caused by minor blunt trauma.

Case presentation

An 83-year-old Japanese man was transported to our hospital 3 hours after falling out of bed. Computed tomography revealed hemothorax and multiple rib fractures. He underwent fluid resuscitation and a tube thoracostomy, but he became hemodynamically unstable. Contrast-enhanced computed tomography revealed worsening hemothorax with contrast extravasation 4 hours after arrival at the hospital. Emergency angiography indicated hemorrhage in the area supplied by the tenth intercostal artery. Transcatheter arterial embolization stabilized his vital signs for a short period. However, further hemodynamic stabilization required a thoracotomy, which revealed diaphragmatic trauma, which was removed and sutured before fixing his fractured ribs. His postoperative course was uneventful, and he was transferred to another hospital for rehabilitation without complications on hospital day 29.

Conclusions

Minor mechanisms of blunt trauma can cause rib fractures and massive hemothorax. Traumatic diaphragm injury should be considered a differential diagnosis if hemodynamic instability persists after transcatheter arterial embolization in patients with lower level rib fractures.

Missed diagnosis of a large, right-sided diaphragmatic rupture with herniated liver and concomitant liver laceration after blunt trauma: consequences for delayed surgical repair

Diaphragmatic injuries are relatively rare and as such frequently missed, particularly if they occur as a rare event on the right-sided dome. Even if detected in the early phase, the concomitant injury of other organs may delay the time to repair. The delay in surgical correction may aggravate additional adherences between thoracic and abdominal organs and cause the diaphragmatic muscle to retract, causing a larger tissue defect that may prevent primary suture repair. This should be taken into consideration when choosing access to repair (thoracic, abdominal or both cavities), mode (open or laparoscopic) and type of repair (primary suture or use of mesh material to close the defect). Here we present a case of delayed right-sided, blunt diaphragmatic injury with herniation of liver. Repair was performed in a delayed manner with an initial laparoscopic exploration converted to open abdominal repair with closing of defect with Gore-tex mesh material.

Laparoscopy in Blunt Abdominal Trauma: for Whom? When?and Why?

The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.