Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Article
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

References

  1. Shah R, Sabanathan S, Mearns AJ, Choudhury AK (1995) Traumatic rupture of diaphragm. Ann Thorac Surg 60(5):1444–1449. https://doi.org/10.1016/0003-4975(95)00629-Y

    Article  CAS  Google Scholar 

  2. Regel G, Lobenhoffer P, Lehmann U, Pape HC, Pohlemann T, Tscherne H (1993) Ergebnisse in der Behandlung Polytraumatisierter. Eine vergleichende Analyse von 3406 Fällen zwischen 1972 und 1991 [Results of treatment of polytraumatized patients. A comparative analysis of 3,406 cases between 1972 and 1991]. Unfallchirurg 96(7):350–62. German

  3. Adegboye VO, Ladipo JK, Adebo OA, Brimmo AI (2002) Diaphragmatic injuries. Afr J Med Med Sci 31(2):149–153

    CAS  Google Scholar 

  4. Tokgöz S, Akkoca M, Uçar Y, Yilmaz KB, Sevim Ö, Gündoğan G (2019) Factors affecting mortality in traumatic diaphragm ruptures. Ulus Travma Acil Cerrahi Derg 25(6):567–574. English. https://doi.org/10.14744/tjtes.2019.58133

  5. Mihos P, Potaris K, Gakidis J, Paraskevopoulos J, Varvatsoulis P, Gougoutas B et al (2003) Traumatic rupture of the diaphragm: experience with 65 patients. Injury 34(3):169–172. https://doi.org/10.1016/s0020-1383(02)00369-8

    Article  Google Scholar 

  6. Asensio JA, Petrone P, Demetriades D (2004) Injury to the diaphragm. In: Moore EE, Feliciano DV, Mattox KL (eds) Trauma, 5th edn. McGraw-Hill, New York, NY, pp 613–35

    Google Scholar 

  7. Davis J, Eghbalieh B (2008) Injury to the diaphragm. In: Feliciano D, Mattox K, Moore E (eds) Trauma, 6th edn. McGraw Hill High Educ, p 623–35

  8. Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S (2009) Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg 52(3):177–81

    Google Scholar 

  9. Zarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC (2013) Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg 74(6):1392–8; quiz 1611. https://doi.org/10.1097/TA.0b013e31828c318e

  10. Meteroğlu F, Şahin A, Başyiğit İ, Oruç M, Monıs S, Sızlanan A et al (2015) Toraks travması takibinde dikkat edilmesi gereken durum: Diyafragma yaralanmaları [Diaphragmatic injury: condition be noticed in the management of thoracic trauma]. Ulus Travma Acil Cerrahi Derg 21(6):514–9. Turkish. https://doi.org/10.5505/tjtes.2015.30660

  11. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA (2015) Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg 209(5):864–8; discussion 868–9. https://doi.org/10.1016/j.amjsurg.2014.12.023

  12. D’Souza N, Clarke D, Laing G (2017) Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service. Ann R Coll Surg Engl 99(5):394–401. https://doi.org/10.1308/rcsann.2017.0029

    Article  CAS  Google Scholar 

  13. Petrone P, Asensio JA, Marini CP (2017 Jan) Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Curr Probl Surg 54(1):11–32. https://doi.org/10.1067/j.cpsurg.2016.11.001

    Article  Google Scholar 

  14. Bocchini G, Guida F, Sica G, Codella U, Scaglione M (2012) Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging. Emerg Radiol 19(3):225–235. https://doi.org/10.1007/s10140-012-1025-4

    Article  Google Scholar 

  15. Moore EE, Malangoni MA, Cogbill TH, Shackford SR, Champion HR, Jurkovich GJ et al (1994) Organ injury scaling. IV: thoracic vascular, lung, cardiac, and diaphragm. J Trauma 36(3):299–300

  16. Gennarelli TA, Wodzin E (2008) The Abbreviated Injury Scale 2005 - Update 2008.  Association for the Advancement of Automotive Medicine, Barrington

  17. Symbas PN, Vlasis SE, Hatcher C Jr (1986) Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 42(2):158–162. https://doi.org/10.1016/s0003-4975(10)60510-3

    Article  CAS  Google Scholar 

  18. Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D et al (1993) Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma 34(6):890–8; discussion 898–9. https://doi.org/10.1097/00005373-199306000-00022

  19. Huber-Wagner S, Biberthaler P, Häberle S, Wierer M, Dobritz M, Rummeny E et al (2013) TraumaRegister DGU. Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study. PLoS One 8(7):e68880. https://doi.org/10.1371/journal.pone.0068880

  20. Mintz Y, Easter DW, Izhar U, Edden Y, Talamini MA, Rivkind AI (2007) Minimally invasive procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct diagnosis in selected patients. Am Surg 73(4):388–392

    Article  Google Scholar 

  21. Mirvis SE, Shanmuganagthan K (2007) Imaging hemidiaphragmatic injury. Eur Radiol 17(6):1411–1421. https://doi.org/10.1007/s00330-006-0553-2

    Article  Google Scholar 

  22. Hammer MM, Flagg E, Mellnick VM, Cummings KW, Bhalla S, Raptis CA (2014) Computed tomography of blunt and penetrating diaphragmatic injury: sensitivity and inter-observer agreement of CT Signs. Emerg Radiol 21(2):143–149. https://doi.org/10.1007/s10140-013-1166-0

    Article  Google Scholar 

  23. Deutsche Gesellschaft für Unfallchirurgie (2016) S 3 – Leitlinie Polytrauma/Schwerverletzten-Behandlung. AWMF online, p 338–329

  24. Lefering R, Huber-Wagner S, Nienaber U, Maegele M, Bouillon B (2014) Update of the trauma risk adjustment model of the TraumaRegister DGU™: the Revised Injury Severity Classification, version II. Crit Care 18(5):476. https://doi.org/10.1186/s13054-014-0476-2

    Article  Google Scholar 

  25. Baker SP, O’Neill B, Haddon WJR, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma Acute Care Surg 14(3):187–196

    Article  CAS  Google Scholar 

  26. Bosanquet D, Farboud A, Luckraz H (2009) A review diaphragmatic injury. Respir Med CME 2:1–6. https://doi.org/10.1016/j.rmedc.2009.01.002

    Article  Google Scholar 

  27. Rudloff U, Pachter H (2008) Diaphragmatic Injuries. Curr Surg Ther vol 9, 9th edn. Elsevier Health Sciences, St. Louis, p 975–87

  28. Bonatti M, Lombardo F, Vezzali N, Zamboni GA, Bonatti G (2016) Blunt diaphragmatic lesions: Imaging findings and pitfalls. World J Radiol 8(10):819–828. https://doi.org/10.4329/wjr.v8.i10.819

    Article  Google Scholar 

  29. Dreizin D, Borja MJ, Danton GH, Kadakia K, Caban K, Rivas LA et al (2013) Penetrating diaphragmatic injury: accuracy of 64-section multidetector CT with trajectography. Radiology 268(3):729–737. https://doi.org/10.1148/radiol.13121260

    Article  Google Scholar 

  30. Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG (2002) Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 22, Spec No:S103–16; discussion S116–8. https://doi.org/10.1148/radiographics.22.suppl_1.g02oc14s103

  31. Reiff DA, McGwin G Jr, Metzger J, Windham ST, Doss M, Rue LW III (2002) Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture. J Trauma 53(6):1139–1145. https://doi.org/10.1097/00005373-200212000-00018

    Article  Google Scholar 

  32. Hood RM (1971) Traumatic diaphragmatic hernia. Ann Thorac Surg 12(3):311–324. https://doi.org/10.1016/s0003-4975(10)65131-4

    Article  CAS  Google Scholar 

  33. Farboud A, Luckraz H, Butchart EG (2008) Delayed presentation of diaphragmatic injury secondary to rib fracture. Respir Med CME 1:158–160. https://doi.org/10.1016/j.rmedc.2008.03.008

    Article  Google Scholar 

  34. Kim S, Choi WJ, Lee KH, Byun CS, Bae KS, Park IH (2017) The clinical implications of severe low rib fracture in the management of diaphragm injury: a case control study. Int J Surg 42:178–182. https://doi.org/10.1016/j.ijsu.2017.04.055

    Article  Google Scholar 

  35. Bieler D, Franke AF, Hentsch S, Paffrath T, Willms A, Lefering R et al (2014) TraumaRegister DGU. Schuss- und Stichverletzungen in Deutschland--Epidemiologie und Outcome : Eine Analyse aus dem TraumaRegister DGU® [Gunshot and stab wounds in Germany--epidemiology and outcome: analysis from the TraumaRegister DGU®]. Unfallchirurg 117(11):995–1004. German. https://doi.org/10.1007/s00113-014-2647-7

  36. Freeman RK, Al-Dossari G, Hutcheson KA, Huber L, Jessen M, Meyer D (2001) Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg 72:342–347. https://doi.org/10.1016/S0003-4975(01)02803-X

    Article  CAS  Google Scholar 

  37. Scharff JR, Naunheim KS (2007) Traumatic diaphragmatic injuries. Thorac Surg Clin 17:81–85. https://doi.org/10.1016/j.thorsurg.2007.03.006

    Article  Google Scholar 

  38. Mahamid A, Peleg K, Givon A, Alfici R, Olsha O, Ashkenazi I (2017) Blunt traumatic diaphragmatic injury: a diagnostic enigma with potential surgical pitfalls. Am J Emerg Med 35:214–217. https://doi.org/10.1016/j.ajem.2016.10.046

    Article  Google Scholar 

  39. Gielis M, Bruera N, Pinsak A, Olmedo I, Fabián PW, Viscido G (2022) Laparoscopic repair of acute traumatic diaphragmatic hernia with mesh reinforcement: a case report. Int J Surg Case Rep 93:106910. https://doi.org/10.1016/j.ijscr.2022.106910

  40. Boulanger BR, Milzman DP, Rosati C, Rodriguez A (1993) A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 35:255–260. https://doi.org/10.1097/00005373-199308000-00014

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We would like to thank the members of the Polytrauma Study Group of the German Trauma Society for their many years of hard work and commitment to TraumaRegister DGU®. In 2007, the Polytrauma Study Group was integrated into the Committee on Emergency Medicine, Intensive Care, and Trauma Management (Sektion NIS) of the German Trauma Society (DGU).

We also would like to thank the German Office of Languages in Hürth for linguistic support.

Author information

Author notes

    Authors and Affiliations

    1. Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital, Rübenacher Straße 170, 56072, Koblenz, Germany

      Carsten Weber, Arnulf Willms, Christof Schreyer, Sebastian Schaaf, Robert Schwab & Christoph Güsgen

    2. Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Plastic Surgery, and Burn Medicine, Hand Surgery, German Armed Forces Central Hospital, Rübenacher Straße 170, 56072, Koblenz, Germany

      Dan Bieler & Erwin Kollig

    3. Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Moorenstraße 5, 40225, Düsseldorf, Germany

      Dan Bieler

    4. Institute for Research in Operative Medicine, Witten-Herdecke University, Ostmerheimer Straße 200, 51109, Cologne, Germany

      Rolf Lefering

    Authors
    1. Carsten Weber
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Arnulf Willms
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Dan Bieler
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Christof Schreyer
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Rolf Lefering
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Sebastian Schaaf
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Robert Schwab
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. Erwin Kollig
      View author publications

      You can also search for this author in PubMed Google Scholar

    9. Christoph Güsgen
      View author publications

      You can also search for this author in PubMed Google Scholar

    Consortia

    and the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU)

    Corresponding author

    Correspondence to Christof Schreyer.

    Ethics declarations

    Ethics approval

    Not applicable. The manuscript does not report on or involve the use of any animal or human tissue.

    Consent for publication

    Not applicable.

    Competing interests

    DB is a member of the Committee on Emergency Medicine, Intensive Care, and Trauma Management (Sektion NIS) of the German Trauma Society (DGU). RL is a consultant for AUC GmbH and has received research support (third-party funds) from AUC GmbH. DB is the speaker of the working group TraumaRegister DGU® of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS). The other authors (AW, CG, CW) declare that they have no competing financial interests. They received no financial funding.

    Additional information

    Publisher's note

    Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

    Carsten Weber and Arnulf Willms contributed equally to this work and shared their first authorship.

    Rights and permissions

    Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Weber, C., Willms, A., Bieler, D. et al. Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome—an analysis based on the TraumaRegister DGU®. Langenbecks Arch Surg 407, 3681–3690 (2022). https://doi.org/10.1007/s00423-022-02629-y

    Download citation

    • Received:

    • Accepted:

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s00423-022-02629-y

    Keywords

    Search

    Navigation