Acute injuries of the diaphragm

Natural evolution of perforating wounds of 30% extension of the left diaphragm and the anatomopathological characteristics of its healing. Experimental Study

INTRODUCTION

diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism?

OBJECTIVE

to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm.

METHOD

50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar.

RESULTS

it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples.

CONCLUSION

Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.

Our surgical experience in traumatic and congenital diaphragmatic hernia: Single-center study

Background and Aim

Diaphragmatic hernias can develop congenitally or secondary to trauma. Congenital diaphragmatic hernias occur with Bochdalek hernia and Morgagni hernia (MH). In this study, we aimed to present laparoscopic and open surgical treatment for traumatic and congenital diaphragmatic hernias, and complications and length of hospital stay in the light of the literature.

Patients and Methods

Twenty-two patients who were diagnosed with diaphragmatic hernia between January 2013 and January 2020 in our clinic were examined retrospectively in terms of demographic features, clinical and radiological findings, and length of hospital stay.

Results

The complaints of the patients diagnosed with diaphragmatic hernia were often abdominal pain, shortness of breath, early satiety, nausea, vomiting, and abdominal distention. The mean age of the patients was 54 (19-88) years. Sixteen patients were females and six were males. Two patients were operated due to stab injury, six patients were operated due to ileus, and the remaining fourteen patients were operated due to congenital diaphragmatic hernia. Eight patients were operated under emergency conditions. The remaining patients were operated under elective conditions. The average hospital stay was 6(3-15) days. The length of hospital stay of those who underwent laparoscopic surgery was 4 (3-5) days. No patient had an exitus. All patients were discharged with healing. This rare pathology should be remembered especially in patients presenting with acute abdominal complaints accompanied by respiratory complaints.

Conclusion

We think that cases with MH detected incidentally should be operated laparoscopically before becoming complicated.

Evolução natural das feridas perfurocortantes de 30% de extensão do diafragma esquerdo e das características anatomopatológicas de sua cicatrização. Estudo Experimental

RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.

Penetrating Thoracoabdominal Trauma With a Cryptic Diaphragmatic Injury in a 23-Year-Old Male

Traumatic diaphragmatic injuries are a rare entity and can occur in relation to penetrating thoracic and abdominal trauma. The most common clinical features of diaphragm rupture include chest or abdominal bruising, decreased breath sounds, and signs of bowel obstruction. However, the classic signs and symptoms of diaphragmatic injury are not always present and can be obscured even in the highest resolution imaging. This highlights the importance for maintaining a high index of suspicion to make the diagnosis and properly manage these patients. Here, we present a rare case of a 23-year-old male who experienced a laceration to his left thorax and was later discovered to have concurrent diaphragmatic injury despite an initially noncontributory physical exam and imaging findings. The patient subsequently underwent robotic repair of the injury and reduction of herniated contents.

Innovative and Contemporary Interventions of Diaphragmatic Disorders

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Laparoscopic IPOM repair of an acquired abdominal intercostal hernia

Acquired abdominal intercostal hernia (AAIH) is an infrequent occurrence whereby intra-abdominal contents herniate into intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. These hernias are difficult to diagnose and should always be suspected when a chest wall swelling occur after major or minor trauma. Surgical repair is warranted in symptomatic patients. The majority of AAIHs are repaired through an open approach using tension-free mesh, with significant recurrence risk. Recently, laparoscopic and robot-assisted repairs have been proposed. We discuss a 49-year-old man presented through outpatient setting with a 5-year history of ongoing left subcostal discomfort and a reducible lump. His history included a workplace accident 5 years ago. Contrast-enhanced abdominal CT confirmed AAIH with omentum herniation into the sac. A successful laparoscopic repair with intraperitoneal onlay mesh technique using composite mesh was performed.

Diaphragmatic injuries: challenges in the diagnosis and management

Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging for the trauma surgeon, as it is often clinically occult. Accurate diagnosis is critical however as a missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. The etiology of DI includes the following mechanisms: blunt, penetrating, and iatrogenic. Vital information about the mechanism of injury should be obtained from the emergency medical personnel. Left-sided hemidiaphragmatic injuries are considerably more common than right-sided injuries. Patients with right-sided hemidiaphragm rupture have higher pre-hospital mortality resulting from the greater impacting force require to produce a right-sided DI, associated with significant vascular injury. The diagnosis of a DI by imaging studies presents a challenge, as evidenced by the large number of investigative procedures employed to establish the diagnosis. Minimally invasive technology in the form of laparoscopy and thoracoscopy is in the trauma surgeon's diagnostic and therapeutic armamentarium. The surgical care of DI can be classified according to the phase of clinical presentation, into injuries requiring management in their acute phase versus those in their chronic phase. The patient's survival depends on the severity of their associated injuries, but if DI is not diagnosed promptly a missed injury can be associated with a high morbidity and mortality.

Acquired abdominal intercostal hernia: a case report and literature review

Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra-abdominal contents reach the intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. We discuss a case of a 51-year-old obese female who arrived to the emergency room with a painful swelling between her left 10th rib and 11th rib. She gave a history of a stab wound to the area 15 years earlier. A CT scan revealed a fat containing intercostal hernia with no diaphragmatic defect. An open operative approach with a hernia patch was used to repair this hernia. These hernias are difficult to diagnose, so a high clinical suspicion and thorough history and physical exam are important. This review discusses pathogenesis, clinical presentation, complications, and appropriate treatment strategies of AAIH.

Transdiaphragmatic Intercostal Herniation following Blunt Trauma

Intercostal herniation is very rarely and sporadically reported in the literature. Intercostal hernia can occur following blunt trauma and may be associated with rib fractures. We present a case of a patient who presented with rib fractures, diaphragmatic rupture, and intrathoracic herniation of abdominal contents with subsequent herniation of both lung and abdominal contents through an intercostal defect. The patient was successfully treated with primary surgical repair of the diaphragm and intercostal hernia. The presentation, pathophysiology, and management of this rare clinical entity are discussed.

CT of blunt diaphragmatic rupture

The diagnosis of blunt diaphragmatic rupture (BDR) is difficult and often missed, leaving many patients with this traumatic injury at risk for life-threatening complications. The potential diagnostic pitfalls are numerous and include anatomic variants and congenital and acquired abnormalities. Chest radiography, despite its known limitations, may still be helpful in the early assessment of severe thoracoabdominal trauma and for detecting initially overlooked BDR or late complications of BDR. However, since the development of helical and multidetector scanners, computed tomography (CT) has become the reference standard; thus, knowledge of the CT signs suggestive of BDR is important for recognition of this injury pattern. A large number of CT signs of BDR have been described elsewhere, many of them individually, but the use of various appellations for the same sign can make previously published reports confusing. The systematic description and classification of CT signs provided in this article may help clarify matters and provide clues for diagnosing BDR. The authors describe 19 distinct CT signs grouped in three categories: direct signs of rupture, indirect signs that are consequences of rupture, and signs that are of uncertain origin. Since no single CT sign can be considered a marker leading to a correct diagnosis in every case of BDR, accurate diagnosis depends on the analysis of all signs present.

Management of patients with traumatic rupture of the diaphragm

Background

Traumatic rupture of the diaphragm is an unusual type of trauma. In addition, it is difficult to diagnose because it can be accompanied by injuries to other organs. If it is not detected early, the mortality rate can increase due to serious complications. Diaphragmatic rupture is an important indicator of the severity of the trauma. The aim of this study was to investigate the factors affecting the incidence of complications and mortality in patients who had surgery to treat traumatic rupture of the diaphragm.

Materials and Methods

The subjects were patients who had undergone a diaphragmatic rupture by blunt trauma or stab wounds except patients who were transferred to other hospitals within 3 days of hospitalization, from January 2000 to December 2007. This study was a retrospective study. 43 patients were hospitalized, and 40 patients were included during the study period. Among them, 28 were male, 12 were female, and the average age was 42 (from 18 to 80). Outcome predictive factors including hypoxia, ventilator application days, revised trauma score (RTS), injury severity score (ISS), age, herniated organs, complications, and the mortality rate were investigated.

Results

Causes of trauma included motor vehicle crashes for 20 patients (50%), falls for 10 (25%), stab wounds for 8 (20%), and agricultural machinery accidents for 2 (5%). Most of the patients (36 patients; 90%) had wound sites on the left. Diagnosis was performed within 12 hours for most patients. The diaphragmatic rupture was diagnosed preoperatively in 27 patients (70%) and in 12 patients (30%) during other surgeries. For surgical treatment, thoracotomy was performed in 14 patients (35%), laparotomy in 11 (27.5%), and a surgery combining thoracotomy and laparotomy in 15 patients (37.5%). Herniated organs in the thoracic cavity included the stomach for 23 patients (57.5%), the omentum for 15 patients (37.5%), the colon for 10 patients (25%), and the spleen for 6 patients (15%). Accompanying surgeries included splenectomy for 13 patients (32.5%), lung suture for 6 patients (15%), and liver suture for 5 patients (12.5%). The average hospital stay was 47.80±56.72 days, and the period of ventilation was 3.90±5.8 days. The average ISS was 35.90±16.81 (11~75), and the average RTS was 6.46±1.88 (1.02~7.84). The mortality rate was 17.5% (7 patients). Factors affecting complications were stomach hernia and age. Factors affecting the mortality rate were ISS and RTS.

Conclusion

There are no typical symptoms of the traumatic rupture of the diaphragm by blunt trauma. Nor are there any special methods of diagnosis; in fact, it is difficult to diagnose because it accompanies injuries to other organs. Stab wounds are also not easy to diagnose, though they are relatively easy to diagnose compared to blunt trauma because the accompanying injuries are more limited. Suture of the diaphragm can be performed through the chest, the abdomen, or the thoracoabdomen. These surgical methods are chosen based on accompanying organ injuries. When there are many organ injuries, there are a great number of complications. Significant factors affecting the complication rate were stomach hernia and age. ISS and RTS were significant as factors affecting the mortality rate. In the case of severe trauma such as pelvic fractures, frequent physical examinations and chest X-rays are necessary to confirm traumatic rupture of the diaphragm because it does not have specific symptoms, and there are no clear diagnosis methods. Complications and the mortality rate should be reduced with early diagnosis and with treatment by confirming diaphragmatic rupture in the thoracic cavity and the abdomen during surgery.

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile

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.

Delayed hepatothorax due to right-sided traumatic diaphragmatic rupture

We present a 48-year-old man with delayed hepatothorax due to right-sided traumatic diaphragmatic rupture. An initial chest radiograph showed no specific signs except elevation of the right diaphragmatic border. The diagnosis was confirmed by coronal reformatted helical computed tomography (CT) imaging, which revealed intrathoracic displacement of the liver. A follow-up chest radiograph revealed gradual elevation of the right diaphragmatic border, suggesting worsening of the diaphragmatic rupture and progression of hepatothorax, resulting in severe atelectasis of the right lung. Therefore, surgical repair of the diaphragmatic rupture was performed. Impaction of the liver through the diaphragmatic ruptured region was observed. Chest radiographic examination after the operation revealed a more normal position of the right diaphragmatic border and resolution of the right lung atelectasis. The problems associated with the diagnosis and operative treatment of hepatothorax with right-sided traumatic diaphragmatic ruptures are discussed in the light of this case report.

Pediatric major trauma: an approach to evaluation and management

Trauma is the leading cause of death in children nationwide. Proper management of the pediatric trauma patient involves many of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences in the pediatric population, clinicians will be assured the best possible outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.

Imaging hemidiaphragmatic injury

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.

Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma

BACKGROUND

The purpose of this study was to determine the incidence of thoracic sepsis following a systematic thoracic cavity washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma.

METHODS

Prospectively collected data on all patients presenting with penetrating thoracoabdominal trauma between July 1999 and July 2002 were analysed. Patients with peritoneal biliary-gastroenteric (BGE) contamination and a diaphragmatic laceration were managed by laparotomy and transdiaphragmatic thoracic lavage.

RESULTS

A total of 217 patients had penetrating thoracoabdominal injuries, of whom 110 had BGE contamination of the peritoneal cavity with spillage into the pleural cavity. The mean Injury Severity Score was 38.1. Gunshot and stab wounds occurred in 79 (71.8 per cent) and 31 (28.2 per cent) respectively. Contamination was from the stomach (55.4 per cent), large bowel (37.3 per cent), small bowel (29.1 per cent), gallbladder and bile ducts (9.1 per cent) and pancreas (6.4 per cent). Thoracic complications occurred in six patients (5.5 per cent): empyema in two, Escherichia coli-related pneumonia in three and pleuritis in one. There were no deaths.

CONCLUSION

A thoracic washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma and BGE contamination was associated with a low rate of intrathoracic septic complications.

Predictors of Mortality in Patients with Traumatic Diaphragmatic Rupture and Associated Thoracic and/or Abdominal Injuries

This is a retrospective review of 731 patients sustaining diaphragmatic trauma over a 22 year period (1980–2002) at an urban level I trauma center. Patients had an average injury severity score (ISS) of 22 ± 12. The mortality rate (MR) was 23 per cent (168/731). There were a total of 460 left-sided diaphragmatic injuries (L-TDR), 263 right-sided diaphragmatic injuries (R-TDR), and 8 bilateral diaphragmatic injuries (B-TDR). There were no significant differences in mortality with L-TDR versus R-TDR. Shotgun wounds had the highest MR (42%) ( P = 0.0028). Emergency thoracotomies were performed in 31 per cent (225) with a 62 per cent (140) MR. Bilateral thoracotomies had a significantly higher MR of 85 per cent (33/39) compared to the 58 per cent (107/186) for unilateral thoracotomies ( P = 0.0028). Multivariate analysis revealed the most significant independent predictors of mortality to be the revised trauma score, transfusion of pRBCs > 10 units, and need for thoracotomy (P < 0.0001). The infection rate was 41 per cent. Multivariate analysis revealed blunt trauma, blood transfusions, ISS, and pancreatic injury as the most significant independent predictors of infection ( P < 0.001). The initial physiologic presentation of the patient and the severity of hemorrhagic shock are the primary determinants for survival. Prompt identification of associated injuries with rapid control of bleeding is paramount to survival.

Delayed diagnosis of right-sided diaphragmatic rupture

Diaphragmatic rupture is uncommon and results from either blunt or penetrating trauma. Right-sided traumatic diaphragmatic ruptures are easily missed. We present a case of rupture of the right diaphragm, which highlights the difficulty of confirming the correct diagnosis.

Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury

OBJECTIVE

The objectives of our study were to determine the accuracy of single-detector helical CT (including coronal and sagittal reconstructions) for the diagnosis of traumatic diaphragmatic injury, establish measurements for the thickness of the normal diaphragmatic crus, and describe an additional sign of diaphragmatic injury: active arterial extravasation of contrast material at the level of the diaphragm.

MATERIALS AND METHODS

The CT scans of 25 patients with surgically proven diaphragmatic injury and 22 patients with surgically confirmed uninjured diaphragms were blindly reviewed by five thoracic radiologists. Sagittal and coronal reconstructions were performed for 20 of the 25 patients with a proven diaphragmatic injury and for all the patients without a diaphragmatic injury. Scans were evaluated for findings suggestive of diaphragmatic injury and for associated injuries. Reviewers scored the usefulness of the reconstructed images for establishing the final diagnosis. Measurements of the right and left crura were performed to establish a threshold measurement that would enable radiologists to discriminate between a normal diaphragm and an injured diaphragm.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of helical CT were 84%, 77%, 81%, 81%, and 83%, respectively. Scans showing active arterial extravasation of contrast material enabled reviewers to correctly identify diaphragmatic injury in two patients. Reconstructed images confirmed the correct diagnosis in three patients but supported an incorrect diagnosis in two. The mean thickness of the diaphragmatic crura (right and left) was not significantly greater in patients with an injured diaphragm than in those with an uninjured diaphragm.

CONCLUSION

Helical CT shows good sensitivity, specificity, and accuracy for the diagnosis of diaphragmatic injury. Coronal and sagittal reconstructions are of limited use in establishing or refuting this diagnosis. Active arterial extravasation of contrast material near the diaphragm should raise suspicion for injury. Crus measurements cannot be used to reliably distinguish between injured and uninjured diaphragms.

Imaging of traumatic diaphragmatic injuries

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.

The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture

OBJECTIVE

The objective of our study was to describe the "dependent viscera" sign and determine its usefulness at CT in the diagnosis of diaphragmatic rupture after blunt abdominal trauma.

MATERIALS AND METHODS

The study sample consisted of 28 consecutive patients (19 men, nine women) between 17 and 74 years old (mean age, 31 years) who had undergone abdominal CT and subsequent emergency laparotomy after a blunt trauma. Ten patients had a diaphragmatic rupture (six, right-sided; four, left-sided) at laparotomy. An experienced radiologist unaware of the surgical findings retrospectively reviewed the CT scans, and then a second radiologist reviewed the scans to provide interobserver agreement. Note was made of discontinuity of the diaphragm, intrathoracic herniation of abdominal contents, and waistlike constriction of bowel (the collar sign). Also noted was whether the upper one third of the liver abutted the posterior right ribs or whether the bowel or stomach lay in contact with the posterior left ribs. Either of these findings was termed the "dependent viscera" sign. The radiologists' detection rate of diaphragmatic rupture on the CT scans via observance of the dependent viscera sign was determined. Interobserver agreement was assessed using Cohen's kappa statistic.

RESULTS

The dependent viscera sign was observed on the CT scans of 100% of the patients with a left-sided diaphragmatic rupture and of 83% of the patients with right-sided diaphragmatic rupture. Both observers missed one case of right-sided diaphragmatic rupture. The radiologists' overall rate of detecting diaphragmatic rupture was 90% using the dependent viscera sign. We found excellent interobserver agreement (kappa = 1) for detection of the dependent viscera sign and for the diagnosis of diaphragmatic tear on CT scans.

CONCLUSION

The dependent viscera sign increases the detection at CT of acute diaphragmatic rupture after blunt trauma.

Imaging of diaphragmatic injuries

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.

Imaging diagnosis of nonaortic thoracic injury

Chest radiographs remain the initial imaging modality to rapidly screen patients with blunt chest trauma. Spiral CT is more sensitive and specific in diagnosing most thoracic pathology seen in blunt trauma patients. This article reviews the major clinical and radiologic findings that occur with blunt injuries to the chest, excluding mediastinal vascular injuries.

Ferimentos penetrantes tóraco-abdominais e de tórax e abdome: análise comparativa da morbidade e mortalidade pós-operatórias

Analisamos 145 doentes portadores de ferimentos penetrantes tóraco-abdominais e de tórax e abdome, operados no Serviço de Emergência da Santa Casa de São Paulo de julho de 1987 a fevereiro de 1996, sendo 72 (49,7%) produzidos por arma branca e 73 (50,3%) por projétil de arma de fogo. Foram estudados fatores relacionados à ocorrência de complicações pós-operatórias (pleuropulmonares, abdominais e sistêmicas), ao prolongamento do tempo de permanência hospitalar e à mortalidade ocorrida durante a internação. Caracterizamos os doentes quanto a sua gravidade, através da aplicação de índices objetivos de trauma, tanto fisiológico (RTS) quanto anatômicos (ISS, PATI, PTTI e PTI). Tanto nos ferimentos tóraco- abdominais quanto de tórax e abdome, o tratamento de escolha foi a drenagem pleural associada à laparotomia exploradora. Os ferimentos tóraco-abdominais apresentaram maior incidência de complicações em geral, em relação aos de tórax e abdome, quando a variável controle foi o ferimento produzido por arma branca. A análise por tipo de complicação mostrou que essa diferença foi dada pelo empiema pleural. Não encontramos diferença significante entre esses ferimentos com relação às demais complicações pleuropulmonares infecciosas, abdominais e sistêmicas. Os fatores que se correlacionaram com a evolução para empiema foram: o tipo de órgão lesado (estômago, esôfago e reto), a presença de fístula digestiva, o ferimento produzido por arma branca e a presença de lesão diafragmática. O prolongamento do tempo de permanência hospitalar foi determinado pela ocorrência de complicações e não pela lesão diafragmática. Houve doze (8,3%) mortes no estudo, sendo que a mortalidade correlacionou-se com maior média de lesões orgânicas por doente, com as lesões de rim, grandes vasos e esôfago, com a ocorrência de complicações especialmente de natureza infecciosa e com o ferimento produzido por projétil de arma de fogo. A análise dos nossos resultados permitiu concluir que os ferimentos penetrantes tóraco-abdominais apresentam maior número de lesões orgânicas por doente quando comparados aos ferimentos de tórax e abdome (sem lesão diafragmática), mas esses ferimentos não diferem quanto à mortalidade pós-operatória. Com relação à morbidade, a lesão diafragmática não foi fator determinante do prolongamento do tempo de permanência hospitalar e, na comparação dos ferimentos tóraco-abdominais e de tórax e abdome, a lesão diafragmática produzida por arma branca foi fator determinante do aparecimento de empiema pleural.

Evaluation and management of pediatric major trauma

Proper management of the pediatric trauma patient involves most of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences among the pediatric population, the clinician will be assured the best outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.

Diaphragmatic injuries

A 6-year series of 26 patients with diaphragmatic injury is presented, 15 with rupture from blunt injuries and 11 after penetrating injuries. All had associated injuries and seven died because of these. The diagnosis may be difficult and was consequently delayed in two patients. Eleven ruptured diaphragms were diagnosed before operation, 14 on the operating table and one at autopsy (dead on arrival). Herniation of abdominal organs was seen in nine of 15 patients after blunt injuries. In most patients repair was via laparotomy using absorbable sutures. It is still essential that the surgeon should be aware of the possibility of the diagnosis and the associated severe injuries.

CT in blunt chest trauma: pulmonary, tracheobronchial, and diaphragmatic injuries

Routine use of CT in the initial evaluation of blunt chest trauma is controversial. CT however, has been shown to be useful in the diagnosis of unsuspected chest injuries and in directing therapeutic interventions. This review discusses the CT findings in patients with pulmonary, tracheobronchial, and diaphragmatic injuries after blunt chest trauma.

Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries

BACKGROUND

Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury.

PATIENTS AND METHODS

Hemodynamically stable patients admitted to a level I trauma center with blunt or penetrating injury to the lower chest or abdomen underwent VATS and subsequent celiotomy under the same general anesthetic. Intraoperative thoracoscopic findings were blinded to the abdominal surgeons.

RESULTS

Twenty-six patients were enrolled in the study over a 12-month period. Diaphragmatic injuries were identified in 8 patients (31%). Videothoracoscopy identified all eight injuries in these patients. Six of the 8 patients (75%) with diaphragmatic injuries sustained associated injury to intrathoracic or intra-abdominal organs. There was no mortality and no procedure-related morbidity. There were no missed injuries in patients who underwent VATS.

CONCLUSIONS

Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.

Trauma radiology: part II. Diagnostic imaging of thoracic trauma: review and update

Frontal chest radiographs are the principal diagnostic imaging study to detect, verify, or exclude acute thoracic injury after trauma, and they should be obtained as quickly as possible without compromising clinical assessment and resuscitation. Chest radiographs provide important information about potentially life-threatening conditions, such as tension pneumothorax, major hemothorax, and major arterial injury. In many patients, chest radiographs also provide helpful clues to the presence of such conditions as diaphragmatic rupture, pulmonary contusion/laceration, and tracheobronchial injury. In selected patients, computed tomography scans can supplement information provided by radiography, particularly for detection of mediastinal hemorrhage, aortic pseudoaneurysm, subtle pneumothorax, and delineation of complex pleuroparenchymal processes. On occasion, magnetic resonance imaging can be used to assess integrity of the hemidiaphragms and visceral herniation when other diagnostic studies are equivocal. We consider typical imaging findings associated with a variety of acute thoracic injuries, as well as the most appropriate use of available imaging techniques in different clinical scenarios.

MRI diagnosis of delayed presentation of traumatic diaphragmatic hernia

Traumatic rupture of the diaphragm may go unrecognized in patients with multiple injuries to the abdomen and chest. The majority of undiagnosed diaphragmatic ruptures will eventually become symptomatic and are associated with a high mortality rate if not treated immediately. Multiplanar imaging with magnetic resonance (MR) provided a definitive diagnosis of delayed presentation of traumatic diaphragmatic hernia.

Effort rupture of the diaphragm

Effort rupture of the diaphragm is rare and accounts for only 1% of all diaphragmatic injuries. A 23 year old patient with bilateral rupture that followed sudden movement is described.