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.     

Traumatic rupture of diaphragm with splenic injury

A 56-year-old woman admitted to our hospital because of injury by a road accident. A chest X-ray film and computed tomography (CT) scan showed multiple left rib fractures, hemothorax in the left pleural cavity, and obscurity of the left diaphragm. The stomach and injured spleen were also shown to shift to the left thoracic cavity. The patient was diagnosed as having diaphragmatic rupture with hemothorax in the left pleural cavity due to splenic injury. Emergent surgery was performed and massive bleeding was observed in the thoracic and abdominal cavities. After performing splenectomy and replacing the stomach in the abdominal cavity, the diaphragm was repaired. The patient was discharged 66 days after the surgery. Since traumatic diaphragm rupture can lead to hemorrhagic shock associated with injuries to adjacent organs, it is important to establish an accurate diagnosis and to performed appropriate surgical treatment without delay.     

膈肌损伤诊断与治疗的探讨

目的探讨膈肌损伤的诊断与治疗方法。方法对12例膈肌损伤病人临床资料进行回顾性分析,其中11例为闭合性损伤,1例为穿透性损伤,均合并其他脏器损伤,予手术治疗,经胸手术1例,经腹手术7例,经胸腹切口手术4例,术前确诊10例,术中应用胸腔镜辅助治疗12例。结果12例均治愈,无并发症。结论胸部X线及胸腹CT检查是最可靠的诊断方法,并对手术入路选择最有帮助。手术是治疗膈肌损伤的惟一方法,手术入路要视胸、腹部损伤情况而定。     

Traumatic injury to the portal vein.

Traumatic injuries to the upper abdominal vasculature pose difficult management problems related to both exposure and associated injuries. Among those injuries that are more difficult to manage are those involving the portal vein. While occurring rarely, portal vein injuries require specific therapeutic considerations. Between January, 1968, and July, 1974, over 2000 patients were treated operatively for abdominal trauma at the Ben Taub General Hospital. Among these patients, 22 had injury to the portal vein. Seventeen portal vein injuries were secondary to gunshot wounds, 3 to stab wounds, and 2 to blunt trauma. Associated injuries to the inferior vena cava, pancreas, liver and bile ducts were common. Three patients had associated abdominal aortic injuries, two with acute aorto-caval fistulae. Nine patients died from from failure to control hemorrhage. Eleven were long-term survivors, including two who required pancreataico-duodenectomy as well as portal venorrhaphy. Late complications were rare. The operative approach to patients with traumatic injuries to multiple organs in the upper abdomen, including the portal vein, requires aggressive management and predetermined sequential methods of repair. In spite of innumerable associated injuries, portal vein injuries can be successfully managed in a significant number of patients using generally available surgical techniques and several adjunctive maneuvers.     

Traumatic injuries of the diaphragm. Diaphragmatic hernia

Trauma to the diaphragm may be direct or indirect, and herniation may be obscured by concomitant injuries and may remain occult for many years.The early physical signs and symptoms are meager before the abdominal organs have penetrated deeply into the thorax. The progress of injury can be divided into three phases: (1) initial, (2) latent, and (3) obstructive.Most traumatic hernias occur on the left side because of the diminished buffering force on the undersurface of the left hemidiaphragm. Roentgenograms are most often misinterpreted as indicating eventration of the diaphragm, gastric dilatation, or lesions in the lower lung fields or pleura. A dilated stomach in the left pleural cavity may simulate a pneumothorax. Diaphragmatic injury should always be considered in conjunction with trauma to the liver, kidneys, and spleen. Intestinal obstruction may occur with few significant abdominal findings, when most of the involved viscera are in the thorax. The thoracic approach to surgery provides excellent exposure. The herniated viscera which may be adherent to the lung or pericardium can be released conveniently, there is easy access to the diaphragmatic rent, and lacerations near the heart and esophagus can be repaired without fear of further injury. Extensions or separate abdominal incisions may be necessary to manage concomitant injuries, especially in the initial phase.Wounds of the diaphragm are not likely to heal spontaneously; often the omentum or other viscera plug the laceration, thereby preventing acute herniation. However, this same mechanism separates the muscle edges, preventing their union. Traumatic ruptures of the diaphragm are twelve times more common on the left side due to the protection afforded by the liver. Diaphragmatic tears are most common in the dome and the posterior half which are the areas of embryonic weakness. When strangulation of bowel occurs in the thorax, approximately 90 per cent of the cases are due to traumatic hernia of the diaphragm, and when strangulation occurs, the mortality varies from 25 to 66 per cent.     

Muscle strain injury: diagnosis and treatment.

Muscle strain is a very common injury. Muscles that are frequently involved cross two joints, act mainly in an eccentric fashion, and contain a high percentage of fast-twitch fibers. Muscle strain usually causes acute pain and occurs during strenuous activity. In most cases, the diagnosis can be made on the basis of the history and physical examination. Magnetic resonance imaging is recommended only when radiologic evaluation is necessary for diagnosis. Initial treatment consists of rest, ice, compression, and nonsteroidal anti-inflammatory drug therapy. As pain and swelling subside, physical therapy should be initiated to restore flexibility and strength. Avoiding excessive fatigue and performing adequate warm-up before intense exercise may help to prevent muscle strain injury. The long-term outcome after muscle strain injury is usually excellent, and complications are few.     

Traumatic carotid artery dissection: diagnosis and treatment

Early diagnosis and successful management of traumatic carotid artery dissections require a high index of clinical suspicion. The diagnostic study of choice is cerebral arteriography. In this paper, 24 cases of traumatic carotid artery dissection are described. Presenting signs and symptoms include Horner's syndrome, dysphasia, hemiparesis, obtundation, and monoparesis. Patients detected early with mild neurological deficits fared well with treatment, while those with profound neurological deficits and delayed diagnoses had poor outcomes. Aggressive nonsurgical treatment is advocated including anticoagulation therapy for prevention of progressive thrombosis and arterial occlusion and/or distal arterial embolization with resultant cerebral ischemia. Direct surgical thromboendarterectomy is considered to carry high morbidity and mortality rates.     

Traumatic lesions of the diaphragm

The Authors studied 30 cases of diaphragmatic traumatisms from 1972 to 2003 to stress the difficulty to achieve an early diagnosis and the need of their immediate treatment: 26 of these patients were male and 4 female (6.5:1); the pathogenesis was in 50% of cases an open trauma and in 50% a closed trauma. The mean age was 36.6 years (33.4 in the open trauma and 41.4 in the closed). The left hemi-diaphragm was affected more frequently (63%) than the right (37%). The associated lesions were mainly of the parenchymatous abdominal organs (spleen 43.3% and liver 49%), while in the thorax lung was involved in 20% of cases and heart in 3.3%. All patients underwent plastic surgical intervention of the diaphragm. In only one case, particularly severe, the operation consisted in placing a pleuric drain and death occured a few hours later. Mean mortality was 30% (33.3% in open and 26.6% in closed traumas) and mean hospital stay was 36.2 days. Accurate diagnosis in emergency is difficult because of the frequent associated lesions, typical of these patients. Despite of the optimisation of the rescue and the new imaging technologies, the gold standard for treatment is not yet reached. There is still a considerable amount of misdiagnosis, a relevant mean hospitalization, a high mortality and a very high morbidity. The best approach to thoraco-abdominal traumas is still to fear a diaphragmatic lesion up to contrary demonstration, in order to achieve precocious diagnosis and surgical treatment, to avoid complications of delayed treatment.     

Traumatic rupture of the diaphragm

Twelve cases of traumatic tear of the diaphragm have been operated upon. In nine operation was done less than a week after the accident, with eight excellent results and one death. Three cases were recognized late in patients who had sustained chest injuries months or years earlier. Repair was accomplished in all patients through a thoracic approach.     

Traumatic tear of the diaphragm

We have carried out a 9-month retrospective study in the Emergency Resuscitation Unit; 21 patients with abdominal trauma, 42 patients with chest trauma and 895 patients with multiple injuries were treated; 197 (22%) of the latter had also chest and/or abdomen involvement. Of the 260 patients with chest and/or abdomen involvement, six (2.3%) patients had traumatic tear of the diaphragm and four of them, presented thoracic herniation of abdominal content. Diagnostic suspicion was entertained in five patients by means of x-ray plain chest film; diagnosis was confirmed by a barium meal in two patients. In one patient, the diagnosis was established perioperatively. All patients had associated lesions. Four patients required mechanical ventilation after the operation. One patient died of cardiogenic shock on the fourth postoperative day. We emphasize the importance of the suspicion of such condition in patients with multiple injuries with chest and/or abdomen involvement.