Abstract
Background
Blunt diaphragmatic rupture (DR) is a rare condition usually masked by multiple associated injuries, which are the main cause of morbidity and mortality. The overall incidence of diaphragmatic injury is 0.8–5.8% in blunt trauma—2.5–5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. A correct diagnosis remains difficult and is usually made late.
Methods
Over four years 12 patients with blunt DR were treated in our hospital. Their charts and X-rays were analyzed. All the surgeons involved were interviewed. Diagnostic and treatment modalities were analyzed and discussed.
Results
Acute diaphragmatic rupture (ADR) was diagnosed in nine patients within seven days. Three patients presented with bowel obstruction and post-traumatic diaphragmatic hernia was diagnosed intraoperatively. Nine patients had rupture of the left hemidiaphragm, two had rupture of the right hemidiaphragm, and one had bilateral DR. Diagnosis of DR was made in all patients in the ADR group before surgery. The correct diagnosis was made within 12 h by junior medical officers in 66.6% of cases. Two patients were diagnosed on a second chest X-ray in response to progressive respiratory distress. The diaphragmatic defect was repaired in all patients via laparotomy; only one patient required additional thoracotomy. Mortality was 25%.
Conclusions
Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases of DR. Respiratory distress should be treated with intubation as intercostal drainage (ICD) may not improve the situation and is associated with a high risk of iatrogenic injuries. Surgical repair is mandatory and laparotomy should be the preferred approach in unstable patients. To avoid missed injury thorough inspection of both hemidiaphragms should be done routinely on every trauma patient undergoing laparotomy. It is widely recommended to use non-absorbable suturing for diaphragm repair but slowly absorbable material seems reliable also.
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References
Kara E, Kaya Y, Zeybek R, Coskun T, Yavuz C (2004) A case of a diaphragmatic rupture complicated with lacerations of stomach and spleen caused by a violent cough presenting with mediastinal shift. Ann Acad Med Singapore 33:649–650
Hamoudi D, Bouderka MA, Benissa N, Harti A (2004) Diaphragmatic rupture during labor. Int J Obstet Anesth 13:284–286
Serban CS, Stewart RC, Soon SY, Walker WS (2002) Spontaneous rupture of the right hemidiaphragm after video-assisted lung volume reduction operation. Ann Thorac Surg 74:929–931
Gupta V, Singhal R, Ansari MZ (2005) Spontaneous rupture of the diaphragm. Eur J Emerg Med 12(1):43–44
Vaughan P, Hooper PJ, Duffy JP (2005) Spontaneous hemothorax after caesarian section: an unusual manifestation of diaphragmatic fenestrations. Ann Thorac Surg 80:1517–1519
Athanassiadi K, Kalavrouziotis G, Athanassiou M, Vernikos P, Skrekas G, Poultsidi A, Bellenis I (1999) Blunt diaphragmatic rupture. Eur J Cardiothorac Surg 15:469–474
Alensio JA, Demetriades D, Rodrigues A (1996) Injuries to the diaphragm. In: Feliciano DV, Moore EE, Mattox KL (eds) Trauma, 3d edn. Appleton & Lange, Norwalk, CT, pp 461–486
Shah R, Sabanathan S, Mearns AJ, Choudhury AK (1995) Traumatic rupture of diaphragm. Ann Thorac Surg 60:1444–1449
Sliker CW (2006) Imaging of diaphragm injuries. Radiol Clin N Am 44:199–211
Eren S, Kantarcı M, Okur A (2006) Imaging of diaphragmatic rupture after trauma. Clin Radiol 61:467–477
Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review of 12 cases. Clin Radiol 60:1280–1289
Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K (2004) Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 22:601–604
Mihos P, Potaris K, Gakidis J, Paraskevopoulos J, Varvatsoulis P, Gougoutas B, Papadakis G, Lapidakis E (2003) Traumatic rupture of the diaphragm: experience with 65 patients. Injury, Int J Care Injured 34:169–172
Boulanger BR, Milzman DP, Rosati C, Rodriguez A (1993) A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 35(2):255–260
Karmy-Jones R, Jurkovich GJ (2004) Blunt chest trauma. Curr Probl Surg 41:223–380
Spann JC, Nwariaku FE, Wait M (1995) Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries. Am J Surg 170:628–631
Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma 52:560–561
Sirbu H, Busch T, Spillner J, Schachtrupp A, Autschbach R (2005) Late bilateral diaphragmatic rupture: challenging diagnostic and surgical repair. Hernia 9:90–92
Yilmaz M, Isik B, Ara C, Yilmaz S, Kutlu R, Kocak O, Ugras M, Kirimlioglu V (2006) Gastric perforation during chest tube placement for acute diaphragmatic rupture and review of the literature. Injury Extra 37:71–75
Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmazer N, Gurses A (2004) Management of traumatic diaphragmatic rupture. Surg Today 34:111–114
Arak T, Solheim K, Pillgram-Larsen J (1997) Diaphragmatic injuries. Injury 28(2):113–117
Zerey M, Heniford T, Sing RF (2006) Laparoscopic repair of traumatic diaphragmatic hernia. Oper Tech Gen Surg 8(1):27–33
Thomas P, Moutardier V, Ragni J, Giudicelli R, Fuentes P (1994) Video-assisted repair of a ruptured right hemidiaphragm. Eur J Cardiothorac Surg 8(3):157–159
Thillois JM, Tremblay B, Cerceau E, Dehaye B, Gigou F, Destable MD, Azorin JF (1998) Traumatic rupture of the right diaphragm. Hernia 2:119–121
Soundappan SVS, Holland AJA, Cass DT, Farrow GB (2005) Blunt traumatic diaphragmatic injuries in children. Injury, Int J Care Injured 36:51–54
Shapiro MJ, Heiberg E, Durham RM, Luchtefeld W, Mazuski E (1996) The unreliability of ct scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 51:27–30
Acknowledgments
The author is thankful to Professor A Machowski, Head of the Department of Surgery, Polokwane/Mankweng Hospital Complex, for support in this work, and to all involved colleagues for permission to report on their patients.
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Matsevych, O.Y. Blunt diaphragmatic rupture: four year’s experience. Hernia 12, 73–78 (2008). https://doi.org/10.1007/s10029-007-0283-7
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DOI: https://doi.org/10.1007/s10029-007-0283-7