Spinal cord injury associated with blunt traumatic rupture of the diaphragm

The incidence of spinal cord injury associated with blunt traumatic rupture of the diaphragm is extremely low and rarely mentioned in the numerous reports about rupture of the diaphragm. It is thought that more such cases can be found among the fatalities of aircraft accidents and presumably among the fatalities of road traffic accidents as the forces causing such injuries make it unlikely for the casualty to survive. The authors present six cases encountered at Stoke Mandeville Hospital, England, and at Sheba Medical Centre, Israel. Although the mortality of such cases, if the patient survives the original impact, is usually due to associated injuries, early diagnosis is essential as late complications increase the incidence of delayed mortality.     

Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients

During a 9-year period, 60 patients with acutely ruptured diaphragms following blunt trauma were treated in our institution. Diaphragmatic injury was detected within 24 hours of hospital admission in all but two patients. The diagnosis was suggested by upright chest X-ray in 40% of the patients. Diaphragmatic tears were discovered at laparotomy for hemoperitoneum in the remaining patients. At initial evaluation hypotension was present in 67% of the patients, and respiratory distress was evident in 52%. In contrast to traditional teaching, there was a 30% incidence of right hemidiaphragmatic disruption. One patient experienced bilateral diaphragmatic rupture, and two had isolated tears of the pericardial diaphragm. Intra-abdominal organs were herniated through the diaphragmatic defect in only 32% of the patients. There was a 90% incidence of associated intra-abdominal injuries. The diaphragmatic tear was repaired via the abdomen in 53 patients, through a thoracoabdominal incision in five patients, and through the chest in only two cases. All defects were closed primarily. Twelve patients also required thoracotomy for resuscitation and/or correction of intrathoracic injury. Atelectasis was the most frequent postoperative complication, occurring in 65% of the patients. The mortality was 26.7% and was related to associated injuries in all cases.     

Blunt traumatic rupture of the diaphragm

Lesions of the diaphragm are uncommon but important complications of blunt thoraco-abdominal traumas. Their incidence is increasing over the last decades as a consequence of the increase of the road traumatology. Preoperative diagnosis is often difficult especially when the diaphragmatic lesion is associated with other skeletal or visceral injuries that may mask the clinical or radiological signs. The Authors report 12 cases of traumatic lesions of the diaphragm due to blunt trauma observed from 1980 to 1997 and that underwent surgery. In particular they discuss about the importance of an early diagnosis and a correct surgical approach to reduce morbidity and mortality. Nine patients were operated by laparotomy; thoracotomy was performed in one case and the combined approach in the last two patients.     

Management of traumatic rupture of the diaphragm

Traumatic rupture of the diaphragm is a potentially serious injury which presents in different forms depending on the mechanism of the causative trauma. Over a 7 year period, 20 patients (17 male and 3 female) with traumatic rupture of the diaphragm were seen in our unit; their mean age was 25.6 years. Automobile accidents caused the diaphragmatic injuries in 65 per cent of cases while falls from trees were the cause of injury in 10 per cent. Ten patients (50 per cent) were seen within 7 days of the injury and 95 per cent within 3 months. The left hemidiaphragm was ruptured in 85 per cent and the right in 15 per cent of cases. Fifty ribs were fractured in fourteen patients (70 per cent) but there were no pelvic fractures. Fourteen patients (70 per cent) had gastrointestinal visceral herniation into the thorax, the stomach, omentum, colon and spleen being the commonest herniating organs. Successful surgical repair was achieved in 18 patients, 4 of whom also had splenectomy; 2 patients were treated conservatively. A high index of suspicion and early surgical treatment are the mainstay of successful management of traumatic rupture of the diaphragm with or without herniation of abdominal organs.     

Missed diaphragm rupture following blunt trauma.

Traumatic rupture of the diaphragm resulting from blunt trauma remains a challenging clinical entity. Diagnosis remains difficult and is often delayed. A prompt diagnosis requires a high index of suspicion. We describe two patients with ruptured diaphragms in whom the diagnosis was made at different stages of their illness. The diaphragmatic injury reflects the magnitude of their associated injuries and probably contributes to the overall mortality.     

Combined blunt rupture of the diaphragm and thoracic aorta

Two patients with blunt traumatic rupture of the diaphragm and thoracic aorta are presented. This combination of injuries may be seen in the multiply-injured patient. Correct interpretation of chest radiographs is essential. If the diagnosis is made early the patient has a good chance of surviving. The eventual functional impairment is mainly related to the associated fractures.     

Tracheal rupture in a child with blunt chest injury

A 10-year-old boy fell from a tree and sustained blunt injury to his chest. He was brought to the hospital (6 h later) with difficulty in breathing and inability to speak. There was a bruise on the neck and extensive subcutaneous emphysema over the neck and chest and decreased air entry over the right hemithorax. Radiographs revealed a right-sided pneumothorax, pneumomediastinum and tracheal deviation. An intercostal drain (with underwater seal) was inserted and he was transferred to the operating room for bronchoscopy. Anesthesia was induced with IV midazolam and ketamine. The trachea was intubated orally and anesthesia maintained with spontaneous breathing of halothane in oxygen. Flexible fiberoptic bronchoscopy performed via the tracheal tube revealed no injury to bronchi or carina. Bronchoscopy through the tracheal tube withdrawn to the level of the vocal cords revealed a 1-cm long posterior longitudinal tear approximately 2-3 cm below the cords. The surgeons planned a definitive tracheostomy distal to the traumatic tracheal opening. This was difficult and initially unsuccessful because of subcutaneous emphysema. A ureteric catheter was introduced through the tracheal tube and a tracheostomy tube mounted on the fiberoptic bronchoscope, which was then inserted through the surgical tracheostome. This followed the ureteric catheter into the distal trachea and the trachea was successfully cannulated. We review the mechanism of tracheal injuries with special reference to its occurrence in children with blunt injury. We discuss the airway management in these potentially life-threatening injuries.     

Radioisotope-assisted diagnosis of traumatic rupture of the diaphragm

Traumatic rupture of the diaphragm is usually not diagnosed early after injury. We hypothesized that the diagnostic yield could be improved by injecting 50 uC of Tc99m macroaggregated albumin in 300 ml of normal saline solution and using simple scintillation counting. Thirty dogs were divided into four groups, anesthetized, and mechanically ventilated. In all groups, counting was done bilaterally 5 cm from the midline at the sternal notch and at 8, 16, 24, 32, 40, 48, and 56 cm below that level immediately and at 10, 20, and 30 min after instillation of the nuclide. In group I, the nuclide was instilled through a left thoracostomy tube, and counting was done with the dogs in reversed Trendelenberg position. In group II, blunt diaphragmatic rupture was simulated before instillation of the nuclide, and counting was done as in group I. In group III, the nuclide was instilled through a standard peritoneal lavage catheter, and counting was done with the dogs in Trendelenberg position. In group IV, blunt diaphragmatic rupture was simulated, nuclide was instilled, and counting was done as in group III. In each dog, there was no significant difference in the counts per minute (cpm) taken immediately and at 10, 20, and 30 min after instillation. In group I, radioactivity was concentrated in the areas adjacent to the diaphragm. In group II, radioactivity was concentrated at the sites lowest in the abdomen where the mean cpm differed significantly (p = .034) from group I.(ABSTRACT TRUNCATED AT 250 WORDS)