Difficulties in identification of traumatic diaphragmatic injuries

Abstract

Introduction: The diagnosis of traumatic diaphragmatic injury (TDI) still remains a real challenge for the surgeons, and its delay can lead to unfavorable outcomes. Purpose: Assessment of diagnostic tests for the patients with TDI. Methods: The casuistic comprises 17 consecutive patients with TDI admitted to the Emergency Department from 2008 to 2011. The average age was 31 (ranging 17-56) years, with a sex ratio 4,7:1 (male:female). Penetrating thoracoabdominal trauma predominated (76,47%) over blunt injury. There were fourteen (82,35%) left-sided diaphragmatic ruptures. The underlying mechanism for TDI was assaults - 64,70%, followed by falls - 17,65% and motor vehicle collision - 17,65%. The average time from hospital admission to surgical management was 89 (ranging 20-180) min for penetrating wounds, and 806 (ranging 65-2220) min for blunt trauma. The median systolic blood pressure and heart rate were 109 (ranging 40-160) mmHg, and 96 (ranging 74-130) beats per minute, respectively. There were five (29,41%) patients in hypovolemic shock. Alcohol intoxication was present in 35,29% of the cases. The associated injuries in these patients included hollow viscus laceration (5), liver laceration (5), splenic laceration (4), lung injury (3), rib fractures (2), limb fractures (2), pelvic fracture (2), pancreatic injury (2), kidney laceration (1), urinary bladder injury (1), head injury (1). The average Injury Severity Score (ISS) was 27 (ranging 12-48). Only three patients (17,65%) had solitary diaphragmatic injuries. The distribution of severity of diaphragmatic injuries by grade was: grade I - 17,64%, grade II- 41,18%, grade III - 29,41%, grade IV - 11,77%. Results: The majority of patients (62,50%) with penetrating wounds were sent straight by to the operating theatre for vital signs: predominantly performed by laparotomy, and only in 2 cases by thoracotomy. Other patients have been investigated: fourteen patients had chest radiographs, with four (23,53%) patients suspicious of a diaphragmatic rupture, CT scan - performed in 2 cases, excluded TDI. Laparoscopy determined TDI in 3 of 7 cases, while the remaining establishing other injury requiring laparotomy. Postoperative complications occurred in 2 patients: posttraumatic pneumonia, pleurisy and pericarditis. Two people died due to severe polytrauma. The average length of hospital stay was 11 (ranging 4-44) days. Conclusion: TDI remains a difficult diagnostic problem determined by multiple injuries and the severity of polytraumatism. In the presence of a wound over the lower half of the chest and left abdominal flank, as in polytrauma patient, TDI requires a high index of suspicion to prevent further complications. The diagnostic of TDI can be made in complex, dynamically: chest radiograph and CT scanning in blunt injuries, and laparoscopy being the investigation of choice in penetrating ones.