Does a Negative Emergency Celiotomy Exclude the Possibility of Significant Diaphragmatic Injury? A Case Report and Review of the Literature

Management of Traumatic Diaphragmatic Injuries

Diaphragm injuries are rarely seen injuries in trauma patients and are difficult to diagnose. With improving technology, computed tomography has become more reliable, but with increasing rates of non-operative management of both penetrating and blunt trauma, the rate of missed diaphragmatic injury has increased. The long-term complications of missed injury include bowel obstruction and perforation, which can carry a mortality rate as high as 85%. When diagnosed, injuries should be repaired to reduce the risk of future complications.

Diagnostic significance of diaphragmatic height index in traumatic diaphragmatic rupture

Purpose

Traumatic diaphragmatic rupture resulting from blunt trauma is usually severe. However, it is often overlooked during initial evaluation because there are no characteristic signs and symptoms. Thus, this study aimed to determine the clinical characteristics of diaphragmatic rupture caused by blunt trauma and investigate the diagnostic usefulness of diaphragmatic height index (DHI) measured using chest radiographs.

Methods

The cohort comprised patients who were admitted due to diaphragmatic rupture from blunt trauma. Patients were divided into 2 groups; the control group comprised patients with blunt trauma who were matched for age, sex, and Injury Severity Score, while the DHI group comprised patients with diaphragmatic rupture from blunt trauma. Receiver operating characteristic curve was used to determine the cutoff value of DHI for diaphragmatic injury. The sensitivity, specificity, predictability, accuracy, and likelihood ratio of the cutoff were then determined.

Results

A total of 60 patients were confirmed to have diaphragmatic rupture. The mean DHI in patients with diaphragmatic rupture on the right and left side were both significantly different compared to that in the control group. A DHI cutoff value of >1.31 showed 71% sensitivity and 87% specificity for diagnosing right diaphragmatic rupture, while a cutoff value of <0.43 showed 87% sensitivity and 76% specificity for diagnosing left diaphragmatic rupture.

Conclusion

DHI can be useful in the diagnosis of diaphragmatic rupture. DHI as determined using chest radiographs in patients with blunt abdominal trauma, particularly in those ineligible for diagnostic work-up, may help in the diagnosis of diaphragmatic rupture.

Evaluation of Thoracoscopy with Single-Lumen Endotracheal Tube Intubation and Laparoscopy in the Diagnosis of Occult Diaphragmatic Injuries in Penetrating Thoracoabdominal Trauma

Background: The diagnosis of traumatic diaphragmatic injuries (TDIs) after penetrating thoracoabdominal trauma is challenging and conventional imaging is unreliable. Laparoscopy and thoracoscopy are minimally invasive modalities of choice in the diagnosis and management of TDI. A little is known on the value of thoracoscopy with single-lumen endotracheal tube intubation (SLETI) in the diagnosis of occult diaphragmatic injuries, and how it compares with laparoscopy. Methods: A prospective study evaluated thoracoscopy with SLETI as a diagnostic tool for occult TDI. Thoracoscopy was followed by diagnostic laparoscopy to confirm the findings and manage diaphragmatic and intra-abdominal injuries. Results: Thirty-one patients underwent thoracoscopy followed by laparoscopy. Majority were men (n = 27, 87%). The median age was 30 years. Twenty-six patients had stab wounds (83.8%), and 5 had gunshot wounds (16.1%). The incidence of diaphragmatic injury was 42% (n = 13). Thoracoscopy with SLETI correctly identified 12 (92%) patients with diaphragmatic injury, but 1 patient had dense pleural adhesions. Diagnostic laparoscopy identified all injuries. Conclusion: Thoracoscopy with SLETI and laparoscopy are feasible, safe, and accurate approaches in detecting TDI in stable patients with penetrating thoracoabdominal injuries. However, dense pleural adhesions may prevent thoracoscopy. Laparoscopy allows inspection of both hemidiaphragms and diagnoses associated intra-abdominal injuries. The choice of primary technique will depend on the individual clinical scenario.