Traumatic injuries of the diaphragm

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.

Traumatic displacement of stomach - a case report

These days we have fast paced traffic on our roads to help us keep up with our fast paced life. But every boon has a down side and our high velocity traffic is no exception. Here is a case report of a blunt abdominal injury following a road traffic accident. Externally the deceased had only a few grazed abrasions on the forehead and right forearm. But on internal examination of abdomen, it was noticed that the left hemi-diaphragm was torn and the stomach and intestines were found displaced into the left thoracic cavity.

Laceration of the Diaphragm: An Autopsy Series

In the surgical literature, laceration of the diaphragm is reported three times more often on the left side than the right, and bilateral lacerations are uncommon. However, in reported autopsy series, right, left, and bilateral lacerations occur at approximately equal frequencies. Few reports mention lacerations of the diaphragmatic crura. This retrospective case series describes the spectrum of autopsy findings in subjects with diaphragmatic lacerations and includes lacerations of the crura.

Methods

Records were reviewed from a consecutive series of 145 autopsies on subjects who died in traffic accidents or falls or leaps from a great height. The diagnostic standard was direct observation at autopsy.

Results

Twenty-two subjects had laceration of the diaphragm. Of these, four had a right leaf laceration, five had left leaf laceration, five had bilateral leaf lacerations, and nine had crural lacerations. Eight subjects with leaf lacerations also had herniations of viscera through the laceration. The lacerations ranged in length from 4 to 20 cm. All subjects sustained additional trauma to the torso. Nineteen of 22 subjects died of severe central nervous system trauma, cardiac or aortic trauma, or both.

Conclusions

Lacerations of the diaphragmatic crura are more common than previously reported. The incidence of right, left, and bilateral leaf lacerations is similar to that reported in other autopsy series. Lacerations of the diaphragm are associated with severe trauma of the central nervous system, heart, and aorta.

Traumatic diaphragmatic injury: experience from a tertiary emergency medical center

OBJECTIVE

We investigated our 12-year experience of traumatic diaphragmatic injury (TDI) in our emergency medical center. This study aimed to clarify clinical features of TDI and identify factors affecting mortality and morbidity in TDI treatment.

METHODS

We analyzed clinical characteristics, Injury Severity Score (ISS), probability of survival (Ps), and mortality of patients treated for TDI at the Tertiary Emergency Medical Center of Tokyo Metropolitan Bokutoh Hospital between January 1999 and December 2010.

RESULTS

TDI occurred in 28 patients. Of 21 TDI patients (75 %) who underwent surgery, 2 died (operative mortality, 9.5 %). Seven (25 %) presented with cardiopulmonary arrest, and TDI was detected during thoracotomy in the emergency room; all of these patients died. Blunt TDI occurred in 12 patients; penetrating TDI in 16. Blunt trauma patients had significantly more injured organs (3.75 ± 0.28, P = 0.043), higher ISS (P = 0.024), and lower Ps (P = 0.048). Lengths of intensive care unit (ICU) stay and hospital stay were greater in blunt cases than in penetrating cases (P = 0.004 and P = 0.02, respectively). Non-survivors had significantly higher ISS (P < 0.001), lower Ps (P = 0.0025), and larger injured diaphragm size (8.44 ± 1.97, P = 0.048). In blunt cases, delays in diagnosis and repair of TDI led to significantly increased ICU stay (16.25 ± 3.64, P = 0.017).

CONCLUSION

TDI occurs in cases of multiple trauma. Higher ISS and lower Ps predict death; therefore, prompt diagnosis of TDI and immediate repair of diaphragmatic injury are important.

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.

Treating traumatic injuries of the diaphragm

Traumatic diaphragmatic injury (DI) is a unique clinical entity that is usually occult and can easily be missed. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of DI challenging to the trauma surgeons. An emergency laparotomy and thorough exploration followed by the repair of the defect is the gold standard for the management of these cases. We report a case of blunt DI in an elderly gentleman and present a comprehensive overview for the management of traumatic injuries of the diaphragm.

Hepatothorax: a rare outcome of high-speed trauma

Diaphragmatic ruptures are the result of severe blunt trauma or penetrating trauma. Motor vehicle crashes are a common mechanism associated with blunt diaphragmatic rupture (BDR). Incorporating diagnostic tools and laparotomy assist in the diagnosis and treatment of BDR. However, diagnosing BDR can be a challenge for practitioners. Early diagnosis and treatment improve the patient's outcomes. This paper details the events of a patient received in a level I trauma unit.

CT with Coronal Reconstruction Identifies Previously Missed Smaller Diaphragmatic Injuries after Blunt Trauma

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).

Tension gastrothorax-colothorax secondary to traumatic diaphragmatic hernia

Traumatic diaphragmatic hernia secondary to diaphragmatic injury is a recognized complication following trauma. It is frequently unrecognized in acute trauma, and delayed presentations with complications are not uncommon.We report the case of a 12-year-old boy presenting in respiratory distress 1 year after blunt abdominal trauma. A chest radiograph demonstrated dilated bowel loops in the left hemithorax mimicking tension pneumothorax. At emergency laparotomy, dilated sigmoid colon was found in the left hemithorax. The hernia was reduced, and a noncongenital diaphragmatic defect was repaired.Although well described in patients with congenital diaphragmatic hernia, tension gastrothorax-colothorax has not been well characterized in traumatic diaphragmatic hernia. We present the second reported pediatric case and discuss the diagnostic workup, operative approach, and postoperative course of this unusual condition.

Traumatic diaphragmatic injuries in children: do they really mark the severity of injury? Our experience

PURPOSE

Diaphragmatic injuries have been reported to be a predictor of serious associated injuries in trauma and a marker of severity. Because of its rarity in children, the diagnosis is often delayed for months and years, due to overshadowing injuries. Perhaps due to the elasticity of their tissues, traumatic diaphragmatic rupture is uncommon in children. The problem remains a challenging clinical entity and the description of such type of injuries in children remains scarce in the literature. Most of the cases are described along with associated injuries; presence of isolated diaphragmatic injuries in children is unusual. The present study highlights the presentation, diagnosis and management of all of the cases admitted with traumatic diaphragmatic injuries in a single pediatric surgical center.

METHODS

We retrospectively studied eight children admitted to our center with a diagnosis of diaphragmatic injury following trauma during a period of 5 years (2003-2008). Relevant information regarding the mode and pattern of injuries were noted in all cases. Type of injury and surgical intervention and outcome of patients were evaluated.

RESULTS

Mean age of presentation was 6.8 years (range 2-12 years). Seven patients were males, while one patient was female. Seven patients had a history of blunt trauma abdomen some time back. Only one patient had acute presentation with respiratory distress following road traffic accident, rest of the patients had no associated grievous injury at the time of presentation. One patient presented with features of acute obstruction. All patients could be diagnosed preoperatively and surgical intervention was performed in all cases. The patients recovered well and there was no mortality.

CONCLUSION

Diaphragmatic injuries in children are rare. They are usually associated with other severe injuries; however, isolated diaphragmatic injuries occur more frequently in children than adults. A high index of clinical suspicion supported by prompt radiological tests is needed to diagnose these injuries in patients who otherwise have no associated grievous injuries.

Minimally Invasive Procedures for Diagnosis of Traumatic Right Diaphragmatic Tears: A Method for Correct Diagnosis in Selected Patients

Traumatic rupture of the diaphragm is no longer uncommon. Because of the increasing frequency of motor vehicle accidents, the rate of blunt trauma to the chest and abdomen, which are the most common causes of diaphragmatic rupture, is increased as well. However, the diagnosis is frequently missed or delayed because of the lack of sensitivity and specificity of imaging modalities. Diagnostic laparoscopy is considered a standard tool for penetrating injuries to the left diaphragm and is widely practiced in selected cases. Right diaphragmatic tears, however, are more difficult to diagnose because of the sealing effect of the liver. Blunt abdominal trauma can cause large right diaphragmatic tears, causing liver incarcerations and respiratory compromise, therefore demanding the need for a comparable diagnostic tool. A high index of suspicion, together with knowledge of the mechanism of trauma, is the key factor for the correct diagnosis. Once the diagnosis has been considered, diagnostic laparoscopy and/or diagnostic thoracoscopy should be performed to confirm or rule out this injury. Factors suggestive of a right diaphragmatic tear include newly or progressive elevation of the right diaphragm and respiratory distress without underlining lung injury. The timing of the procedure should be in accordance with the hemodynamic and respiratory status of the patient. This procedure should be performed semielectively if there are no other indications for surgical intervention.

Blunt traumatic diaphragmatic injuries in children

Diaphragmatic injuries following blunt trauma are rare. From January 1988 to February 2002 eight children were treated at the Children's Hospital at Westmead for diaphragmatic injury. Male to female ration was 5:3. Motor vehicle crashes were the most common cause. The injury was left-sided in four, right sided in three and central in one. Initial plain radiograph and computerised tomography detected the injury in 50% of cases. Laparotomy, contrast study and autopsy identified the rupture in one each. Associated injuries were present in all cases. Seven children had laparotomy and repair of the diaphragmatic rupture. The commonest site of rupture was posterolateral (37.5%). Diagnosis was delayed in two cases. There were two deaths (25% mortality) in the series, both due to associated injuries. Although rare, diaphragmatic rupture must be considered in any child with thoracoabdominal injury. Diagnosis may be difficult and require extensive investigation. Mortality usually results from associated injuries.

Hémothorax droit intarissable révélateur d'une plaie hépatique avec rupture diaphragmatique

We report a case of a woman with a blunt thoracic trauma and haemorrhagic shock after a road traffic accident. The clinical and complementary examinations revealed an isolated right haemothorax, which was compressive and uncontrollable. The source of bleeding was discovered with delay and during a surgical exploration: it was a liver injury with diaphragmatic rupture but without hepatic herniation and peritoneal effusion. The diagnostic features of blunt diaphragmatic rupture are discussed.

Occult trauma in high-risk populations

Several groups of patients are at increased risk for traumatic injury that is "occult," or not apparent on initial presentation. Perhaps the most notorious are those who abuse alcohol, but other groups include the elderly, coagulopathic, those with neurological disease, and the mentally ill. Moreover, traumatic injury can coexist with (or be masked by) medical pathology, resulting in the disposition of injured patients to nonsurgical services where surveillance for traumatic injury diminishes. Because delays or failures in diagnosis might result in unnecessary pain, morbidity, and mortality, it is important for the emergency physician to identify occult presentations of trauma before disposition. This review highlights commonly missed traumatic injuries in adult patients.

Minimally invasive diagnosis and treatment of traumatic rupture of the right hemidiaphragm with liver herniation

We report a case of blunt traumatic rupture of the right hemidiaphragm with liver herniation. A 57-year-old man admitted in an emergency after a traffic accident was suspected from chest radiography and computed tomography to have traumatic diaphragmatic rupture. Magnetic resonance imaging was helpful in the final diagnosis. Thoracoscopy was useful in planning surgery and surgically repairing the ruptured diaphragm.

Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture

BACKGROUND

Diaphragmatic rupture (DR) remains a diagnostic challenge because of the lack of an accurate test demonstrating the injury. Our purpose was to identify motor vehicle collision (MVC) characteristics and patient injuries that collectively could identify the presence of a DR.

METHODS

The National Automotive Sampling System was used to identify occupants involved in MVCs from 1995 to 1999 who sustained abdominal (Abbreviated Injury Scale score >or= 2) and/or thoracic injuries (Abbreviated Injury Scale score >or= 2). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to quantify the association between patient injuries, vehicle collision characteristics, and DR. Sensitivity and specificity were also calculated to determine the ability of organ injury and MVC characteristics to correctly classify patients with and without DR.

RESULTS

Overall, occupants sustaining a DR had a significantly higher delta-V (DeltaV) (49.8 kilometers per hour [kph] vs. 33.8 kph, p< 0.0001) and a greater degree of occupant compartment intrusion (70.6 cm vs. 48.3 cm, p< 0.0001). Specific abdominal and thoracic organ injuries were associated with DR, including thoracic aortic tears (OR, 5.2; 95% CI, 2.2-12.5), splenic injury (OR, 8.4; 95% CI, 3.9-17.8), pelvic fractures (OR, 4.7; 95% CI, 2.7-8.0), and hepatic injuries (OR, 4.2; 95% CI, 1.7-10.6). Combining frontal or near-side lateral occupant compartment intrusion >or= 30 cm or DeltaV >or= 40 kph with specific organ injuries generated a sensitivity for indicating the likelihood of diaphragm injury ranging from 68% to 89%. Patients with any of the following characteristics had a sensitivity for detecting DR of 91%: splenic injury, pelvic fracture, DeltaV >or= 40 kph, or occupant compartment intrusion from any direction >or= 30 cm.

CONCLUSION

Specific MVC characteristics combined with patient injuries have been identified that are highly suggestive of DR. For this subpopulation, additional invasive procedures including exploratory laparotomy, laparoscopy, or thoracoscopy may be warranted to exclude DR.

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.

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma.

METHODS

A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI.

RESULTS

One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound.

CONCLUSIONS

In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.

Diaphragmatic rupture and the association with occupant position in right-hand drive vehicles

Ruptured diaphragm following blunt trauma occurs with an incidence of 3 to 8% with right-sided rupture recognised with increasing frequency. This study aimed to investigate the influence of occupant position in right-hand drive (RHD) vehicles on the side of diaphragmatic injury. A retrospective analysis of the Scottish Trauma Audit Group database was performed to gather data on blunt diaphragmatic lacerations. Police records were also searched to ascertain the point of impact in the accidents studied. In total, 35 patients were studied, 25 drivers and 10 front-seat passengers. The incidence of right-sided rupture was 40% in drivers and 20% in FSPs. The incidence of associated pulmonary contusion, rib fracture and liver injury was also higher in drivers. Given the small sample size, these differences were not statistically significant, but they show an interesting trend. The right side of a driver's body is more exposed to injury in RHD vehicles, a fact that explains the significant association between driver's side impact and right-sided rupture. As right-sided injury is more difficult to detect, it is important that a high index of suspicion is maintained, especially when managing drivers from RHD vehicles.

Diagnosis of Blunt Rupture of the Right Hemidiaphragm by Technetium Scan

Traumatic rupture of the diaphragm, particularly of the right hemidiaphragm, may be occult and can be difficult to diagnose if laparotomy is not required for concomitant injury. Missed or delayed diagnosis of such injuries can produce life-threatening complications, such as intestinal herniation, ischemia, and necrosis. We present a case of traumatic rupture of the right hemidiaphragm that demonstrates the typically occult nature of this injury. The majority of right-sided injuries are diagnosed during laparotomy performed for other injuries. In those patients not requiring laparotomy, the diagnosis is usually delayed because this injury seldom produces clinical or radiographic findings that are either sensitive or specific. In this case, intraperitoneal injection of technetium sulfur colloid was used to establish the diagnosis of right diaphragm rupture, and an uncomplicated repair was undertaken.

Missed diaphragmatic injuries and their long-term sequelae

BACKGROUND

Blunt or penetrating truncal traumas can result in diaphragmatic rupture or injury. Because diaphragmatic defects are difficult to diagnose, those that are missed may present with latent symptoms of obstruction of herniated viscera.

METHODS

A chart review of all patients admitted with late presentations of posttraumatic diaphragmatic hernias from 1980 to 1996 was undertaken.

RESULTS

Ten patients with posttraumatic diaphragmatic hernias were treated in this specified period. There were six males and four females with a mean age of 65 years. Eight patients sustained blunt truncal traumas and two patients sustained penetrating truncal traumas. The hernias occurred in two patients on the right and in eight patients on the left side and contained the liver (n = 2), bowel (n = 10), stomach (n = 4), omentum (n = 5), or spleen (n = 1). The time until the hernias became clinically symptomatic ranged from 20 days to 28 years. In all but one patient, either routine chest roentgenograms or upper gastrointestinal contrast studies were diagnostic. All 10 patients underwent laparotomy (n = 9) or thoracotomy (n = 2) with direct repair of the diaphragmatic defect. One patient died 3 days after the operation, representing a mortality of 10%; the morbidity was 30%.

CONCLUSION

Initial recognition and treatment of diaphragmatic rupture or injury is important in avoiding long-term sequelae.

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.

Thoracic sonography for diagnosis and intervention

Many physicians believe that ultrasound has limited usefulness in chest disease. Our clinical experiences and a review of the literature in preparation for this monograph have convinced us that sonography can be a very useful and versatile tool for thoracic diagnosis and intervention. Although there are some limitations caused by interposed ribs and air-containing lung, almost all of the compartments of the chest can be evaluated with ultrasound, which gives unique and clinically useful information. Ultrasound guidance for biopsy and drainage does take some time to learn, but we feel that the effort is very worthwhile. The same advantages ultrasound enjoys for other body regions make it a modality that will see increased use in the chest as well. We hope that this monograph will stimulate our colleagues to explore and expand upon the techniques described.

Predictors of outcome in blunt diaphragm rupture

OBJECTIVE

Identify outcome predictors in blunt diaphragm rupture (BDR).

DESIGN

Retrospective chart and trauma registry review.

MATERIALS AND METHODS

We reviewed records of patients with BDR from January 1987 through May 1994 for outcomes of mortality, intensive care unit stay, hospital stay, and ventilator days. Predictors tested were age, sex, Injury Severity Score (ISS), diagnostic delay, rupture side, head injury, and associated injuries. Stepwise regression models were developed and tested on an additional data base of 115 BDR records from four trauma centers.

RESULTS

Thirty-two patients were identified. Age was the only significant predictor for all outcomes (p < 0.05). Age, ISS, and severe head injury were mortality predictors. In the larger data base, age and ISS remained predictive of mortality, but age was not predictive of morbidity.

CONCLUSIONS

Age and ISS are predictive of BDR mortality. No morbidity predictor was validated in the larger data base. These data emphasize that predictive models from a single institution should be applied cautiously.

Delayed intrathoracic herniation of the stomach with pleural empyema due to diaphragmatic stab wound

A 32-year-old man received a left-sided thoracic stab wound, which was primarily treated with percutaneous tube thoracostomy. Ipsilateral empyema appeared 8 weeks later and subsequent investigations revealed herniation of the stomach through the diaphragm. The diaphragmatic rupture and a perforation in the gastric wall were repaired at thoracotomy. The literature on such wounds is reviewed.

Ruptured hemidiaphragm: unusual late presentation

Diaphragmatic injuries may be undiagnosed in the acute posttraumatic period and may remain unrecognized despite a variety of chronic symptoms, until eventual emergency department presentation with an intestinal obstruction. We present a case of a female who experienced chronic chest pain during coitus that eventuated in an acute admission with an intrathoracic mesentero-axial volvulus of the stomach, 8 months after a motor vehicle accident. The literature regarding delayed presentation of a ruptured hemidiaphragm is reviewed.

The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture

OBJECTIVE

There is no gold standard for early and reliable diagnosis of traumatic diaphragmatic rupture (TDR). The purpose of this study is to correlate CT scans, chest radiographs, and intubation on the ability to diagnosis traumatic diaphragmatic rupture.

MATERIALS AND METHODS

Twenty patients with blunt trauma induced diaphragmatic rupture were identified from a five year review of a Level 1 Trauma Registry.

RESULTS

Ten of the 20 (50%) patients had TDR on initial chest X-ray, all on the left side. Twelve patients had both chest X-rays and a chest and abdominal CT scan; however, only five (42%) of the CT scans were diagnostic. Of the 12 patients initially intubated, TDR was diagnosed in only four (33%) patients on initial chest X-ray and in one (14%) of seven patients having chest and abdominal CT scans and being intubated.

CONCLUSION

The early diagnosis of blunt traumatic diaphragmatic rupture, especially in intubated patients, continues to be a diagnostic dilemma. There is a significantly better possibility of identifying left over right-sided TDR (P < or = 0.05). Diagnosing TDR is also facilitated by extubation. If the suspicion exists, a post extubation chest radiograph should be performed to evaluate for TDR.

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.

Traumatic rupture of diaphragm

Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture: namely, the diaphragmatic hernia. To analyze the clinical and radiologic features and the therapeutic implications, we reviewed 980 patients reported in the English-language literature. This injury affects predominantly males (male:female = 4:1) in the third decade of life, and is often caused by blunt trauma (75%). There were 1,000 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-sided, 15 (1.5%) bilateral, and 9 (0.9%) pericardial ruptures; 49 cases were unclassified. Chest (43.9%) and splenic (37.6%) trauma were the most common associated injuries. The diagnosis was made preoperatively in 43.5% of cases, whereas in 41.3% it was made at exploration or at autopsy and on the remaining 14.6% of the cases the diagnosis was delayed. The mortality was 17% in those in whom acute diagnosis was made, and the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated evaluation for days after injury is necessary to discern injury in patients not requiring laparotomy. Acute diaphragmatic injuries are best approached through the abdomen, as more than 89% of patients with this injury have an associated intraabdominal injury. Patients with diaphragmatic rupture presenting in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.

Tension Pneumothorax: Etiology, Diagnosis, Pathophysiology, and Management

The normally air-free pleural cavity exists at subatmospheric pressure to promote pleural apposition and proper lung excursion. Owing to its unique bilayer structure, air introduced into this space either from within the thoracic cavity or from an extrathoracic source causes pleural separation and simple pneumothorax (PTX). Most simple pneumothoracies of a small or static volume in healthy patients do not appreciably impair cardiopulmonary function despite variable collapse of the lung. If increasing pressure develops within this pleural air collection, however, a cascade of pathophysiological changes can result from altered anatomical positions of heart, lung, and great vessels. The development of increasing pressure within the pleural space, with resultant ipsilateral lung collapse and hemithoracic expansion into the mediastinum and the contralateral lung, is termed tension pneumothorax (TPTX). The exact incidence of TPTX is unknown, but it is reported in up to 2 to 3% of all pneumothoracies. Certain medical and surgical disease states—many found within the critical care environment—place patients at higher risk for development of TPTX and also limit physiological tolerance to TPTX once it occurs. Although physical examination and chest radiography generally confirm the occurrence of TPTX, physiological monitoring may herald the development of increasing intrapleural pressure. Expeditious recognition and pleural decompression are necessary to prevent the untoward hemodynamic and respiratory consequences of TPTX. Significant morbidity and mortality may arise from TPTX if treatment is unduly delayed, particularly in mechanically ventilated patients.

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.

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.

Rupture of the right hemidiaphragm following blunt trauma: the use of ultrasound in diagnosis

Diaphragmatic rupture occurs in approximately 5% of patients who sustain multiple trauma and post-mortem studies suggest that right-sided rupture is more common than generally realized. Four cases of rupture of the right hemidiaphragm secondary to blunt trauma are presented. The chest radiographs were all similar, demonstrating a right sided fluid collection and right lower lobe consolidation in all patients. No patient had a pneumothorax. CT was useful only in retrospect, demonstrating a posterior eventration of the liver into the thorax in two patients. Ultrasound proved diagnostic in all cases demonstrating either the free edge of the diaphragm as a flap within the pleural fluid or the liver herniating into the thorax. The value of ultrasound as a simple, non-invasive and direct means of imaging the diaphragm is emphasized.

Resection of diaphragmatic peritoneum and muscle: role in cytoreductive surgery for ovarian cancer

Fourteen patients undergoing primary cytoreductive surgery for stage III ovarian malignancies had diaphragmatic peritoneum, muscle, or both resected in an attempt to remove all metastatic disease greater than 0.5 cm in diameter. Resection was completed in 13 of 14 patients (93%), all obtaining optimal cytoreduction. Size of resected specimens varied from 12 x 7 to 17 x 11 cm. The mediastinum was entered in two patients. Four patients had resection of diaphragmatic muscle. All defects were closed primarily and a thoracostomy tube was placed. One patient who did not have muscle resection had a 30% pneumothorax that spontaneously resolved. No subdiaphragmatic hematomas or abscesses occurred. Time (mean 65 min, range 40-150 min) and blood loss (mean 175 ml, range 100-1500 ml) for the surgery depended upon extent of disease. One procedure was terminated due to bleeding from a lacerated liver capsule. We conclude that diaphragmatic peritoneum/muscle resection can be completed successfully with acceptable morbidity.

Blunt rupture of the diaphragm: mechanism, diagnosis, and treatment

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.

Delayed traumatic diaphragmatic hernia simulating acute tension pneumothorax

The diagnosis of acute diaphragmatic injury is difficult to establish in the immediate posttraumatic period. Patients with delayed diaphragmatic herniation frequently present months to years after the initial injury with manifestations of visceral incarceration, obstruction, ischemia from strangulation, or perforation. Patients with diaphragmatic herniation presenting with clinical tension pneumothorax are rare. We describe the case of a 23-year-old female who 16 weeks following a stab wound to the low chest presented with this clinical picture caused by herniation of abdominal viscera into the chest. A review of this entity and methods of discovery of delayed traumatic diaphragmatic herniation are described.

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.

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.

Delayed presentation of traumatic diaphragmatic hernia

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).

Traumatic rupture of the right hemidiaphragm

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.

Blunt traumatic rupture of the right hemidiaphragm: experience in 12 patients

In a 9-year period (1972 to 1981), 35 patients with blunt traumatic rupture of the diaphragm were seen in our institution; 12 had involvement of the right hemidiaphragm, an incidence of approximately 34%. In 9 of these 12 patients, the right-sided diaphragmatic injuries were seen soon after the accident (acute), and in 3, late after the accident (chronic). A large diaphragmatic rent, usually 10 cm or more, without any predilection to a specific area of the right hemidiaphragm, was a frequent operative finding. Expectedly, the most common viscus that was injured or herniated through the defect was the liver. Total or nearly total herniation of the liver was noted in 5 patients and partial herniation, in 1. Injury to the juxtahepatic vena cava or hepatic vein, or both, was also encountered in 5 patients. This highly lethal injury accounted for the 3 deaths in the series, all of which were directly related to an uncontrollable exsanguinating hemorrhage from the injured vena cava or hepatic vein. The surgical approach for repair of a ruptured right hemidiaphragm is best individualized. The right thoracotomy approach through a right posterolateral incision is preferred for chronic diaphragmatic injury. It is also our choice in patients in whom acute right-sided injuries are definitively diagnosed and who are hemodynamically stable. This approach not only provided the best exposure of the defect, but also made the repair of associated retrohepatic caval injury surprisingly easy in at least 2 of our patients.(ABSTRACT TRUNCATED AT 250 WORDS)