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Eur J Cardiothorac Surg 2001;20:53-57
© 2001 Elsevier Science NL

Diaphragmatic injuries

Romaldas Rubikas

Thoracic Surgery Clinic, Kaunas Medical University Hospital, Eiveniu 2, LT-3007 Kaunas, Lithuania

Received 17 April 2000; received in revised form 26 February 2001; accepted 6 April 2001.

Tel.: +370-7-733646; fax: +370-7-798585


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Objectives: (1) To determine the actual incidence rate of blunt and penetrating diaphragmatic injuries (DI); (2) to evaluate the effectiveness of urgent surgical intervention for treatment of DI; and (3) to reveal main causes of postoperative complications. Methods: We reviewed: (1) forensic medical examination charts of 3353 subjects, who died due to polytrauma (including injuries to the chest and/or abdomen) at accident sites; and (2) medical case reports of 4857 patients, treated for thoracoabdominal trauma (TAT) from 1962 to 1998. A detailed analysis was completed with 12 years (1987–1998) of clinical experience, involving 65 (43 penetrating, and 22 blunt) cases of DI. Results: According to forensic medical data, blunt and penetrating DI occurred in 3.7% and 2.6% of individual cases, respectively. Among patients suffering from TAT, it was revealed that blunt DI had occurred in 1.1%, and penetrating in 3.9% of the cases. This data indicates if all the victims, who had sustained TAT, had survived, the incidence rate of DI would have been 2.6% (blunt – 2.1%, and penetrating – 3.4%). All the patients, provided surgical operations due to DI, survived. Morbidity in patients, suffering from blunt and penetrating DI, was 50%, and 35%, respectively. In the group of patients, suffering from penetrating DI, shock, intrapleural and/or intraabdominal haemorrhage, and liver injuries constituted a significant (P<0.05) influence, relevant to development of postoperative complications. The risk of complications was significantly (P<0.05) greater in cases of gunshot injuries. Fractures of chest bones, injuries of abdominal organs, and intraabdominal haemorrhage constituted a significant influence (P<0.05), relevant to development of complications after blunt DI. Conclusions: (1) The danger to the health or even life of patients is not directly caused by DI, but by consequential complications and associated injuries; (2) the effectiveness of treatment is determined by purposeful surgical diagnostics with particular regard to DI and urgent surgical intervention.

Key Words: Thoracoabdominal trauma • Penetrating and blunt diaphragmatic injury • Urgent surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Diaphragmatic injuries (DI) are comparatively so frequent (0.5–8.8%) that medical literature pays disproportionally more attention to this problem [1–5]. The opinion held here is that interest in DI never subsides, because this kind of pathology constantly causes non-typical, and sometimes, almost paradoxical situations. Thoracic and general surgeons inevitably encounter this problem in treating patients, suffering from thoracoabdominal trauma (TAT).

The necessity of urgent surgical intervention before complications of traumatic diaphragmatic hernia (TDH) develop is universally recognised. Main issues under discussion are methods of early diagnostics, optimal surgical approaches for the repair of an injured diaphragm and/or abdominal and thoracic organs [1,6–13].

The purposes of this study were: (1) to determine the actual incidence rate of blunt and penetrating DI in groups of patients, suffering from penetrating and blunt types of TAT; (2) to evaluate the effectiveness of urgent surgical intervention for treatment of DI; and (3) to reveal main causes of postoperative complications.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
The Thoracic Surgery Clinic of Kaunas Medical University (KMU) often admits patients, suffering from severe polytrauma, including TAT, from over half of Lithuania, an area populated by nearly 2 million residents. However, clinical data alone cannot show the true scale of possible injuries. Therefore, the effort was undertaken to learn the incidence rate of DI, as exactly as possible. Reviewed were the forensic medical examination charts of 3353 subjects, who died on site of accidents, and case reports of 4857 patients, treated at the Thoracic Surgery Clinic of KMU from 1962 to 1998.

Comprising the main group of patients examined was 2540 patients, treated for TAT over a 12-year period (1987–1998). Revealed in this group were 43 cases of penetrating, and 22 cases of blunt DI (Table 1).


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  		Table 1. Characteristics of patients suffered from DI

 
The main variables, applied for comparison with the final results of DI treatment, were the age of patients, type and etiology of DI, associated injuries, haemodynamical state of patients on admission, and the time to diagnosis and surgical intervention. Statistical data analysis was performed, using the unpaired t-test. Statistical significance was determined at P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
3.1. Incidence rate of DI
Forensic medical experts discovered DI in 111 of the 3533 subjects, who had died at accident sites. Over the period of this study (1962–1998), surgical operations had been performed on 102 patients of the 4857, who had suffered from TAT, as result of DI. If all the 8210 subjects, who had sustained TAT, would have survived, then the incidence rate of DI among patients, treated at the clinic, would have been 2.6% (Table 2).


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  		Table 2. Incidence rate of DI (1962–1998)

 
3.2. Etiology and location of DI
The most frequent causes of penetrating DI were stab and gunshot wounds to the lower part of the chest and upper part of the abdomen. Traffic accidents were the main causes of blunt DI. The left-sided hemidiaphragm was somewhat more often injured, than the right-sided one (Table 3).


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  		Table 3. Type, etiology and location of DI

 
3.3. Associated injuries
3.3.1. Penetrating injuries
Associated penetrating injuries were revealed in 38 patients (88.5%) in the following organs: lungs in 20 (46.5%) patients, pericardium and heart in five (11.6%), liver in five (11.6%), spleen in three (6.9%), large and small intestines in two (4.6%). Wounds in other parts of the body were diagnosed in 13 (30.2%) of the patients. Haemothorax were present in 20 (46.5%), haemopneumothorax in 16 (37.7%), and haemoperitoneum in nine (18.6%) of the patients.

3.3.2. Blunt injuries
Blunt associated injuries were present in 19 (86.4%) patients, as follows: fractures of chest wall bones (ribs, sternum, clavicula, and vertebral column) in 15 (68.2%); lungs in eight (36.4%); pericardium and heart in five (22.7%); spleen in six (27.3%), and liver in four (18.2%) of the patients. Pelvic and/or lower extremity bone fractures were revealed in seven (31.8%) patients. Head traumas were sustained by eight (36.4%) patients. Haemothorax developed in six (27.3%), haemopneumothorax in five (22.7%), and haemoperitoneum in eight (36.4%) of the patients.

3.4. Diagnosis and treatment of DI
All patients, who had sustained TAT since 1987, were examined with particular regard to DI.

3.4.1. Penetrating DI
Theoretically, DI should be suspected, whenever a penetrating stab or gunshot wound has been sustained in any region of the chest or abdominal wall. Nonetheless, external wounds in 40 of the 43 patients, on whom operations were performed due to penetrating DI, were found on the anterior part of the chest and/or abdominal wall between imaginary lines connecting the nipples and XI ribs. No specific early clinical symptoms or X-ray signs of penetrating DI were found.

Penetrating DI can be divided into two groups, relevant to their treatment strategy. The first group comprised of 35 patients for whom urgent surgical intervention was necessary due to injuries of abdominal or thoracic organs, or severe internal haemorrhage. DI was revealed in this group after surgical exploration of the abdominal or pleural cavity. The second group comprised of eight patients in whom no initial indications for urgent thoracotomy or laparotomy were found. In such cases, an evaluation of the patients was begun with surgical revision of chest wounds. Application of this method revealed peripherally located DI in one patient. Whenever any doubts, concerning DI, remained after revision of chest wounds, laparoscopy or thoracoscopy was performed. Thoracoscopy for visualisation of the diaphragmatic surface was preferred in cases of TAT presenting with haemopneumothorax.

For 25 patients, the dominant feature of TAT was injury to chest organs. In those cases, surgical intervention by thoracotomy was first performed. For 12 of these patients, it was also necessary to perform laparotomy. The other 18 patients were first operated on via laparotomy, and 8 of them also underwent thoracotomy. Penetrating DI were rather small (1–3 cm in diameter), and at the moment of urgent surgical intervention, there was no herniation of the abdominal organs.

3.4.2. Blunt DI
Usually, traumatic diaphragmatic rupture (blunt DI) causes development of TDH. During the initial examination of patients, X-ray signs of TDH (gastric bubble and/or intestines in the chest) were revealed in only seven cases. For the other four patients, blunt DI was diagnosed, using gastrointestinal contrast studies. In four haemodinamicaly stable patients with haemothorax or haemopneumothorax, blunt DI (one, right-sided, and three, left-sided) was revealed by thoracoscopy. In seven of the cases, no blunt DI could be revealed during the first 24 h. Errors in diagnosis were discovered within the first 3 weeks, generally in result of a search to disclose the causes of patient complaints, before their discharge from the hospital. To date, no delayed cases of blunt DI have been observed among the patients, who had been discharged from the Thoracic Surgery Clinic.

Blunt diaphragmatic ruptures measured 5–20 cm in length. These were repaired with interrupted non-absorbable sutures via thoracotomy for 17 patients, and via laparotomy for five patients.

3.5. Outcome in DI
All patients, suffering from penetrating and blunt DI, survived. Aggressive tactics in the management of TAT achieved such results. This involved the purposeful search for DI, and following a diagnosis of such, patients underwent urgent surgical intervention.

3.5.1. Penetrating DI
In 15 (34.8%) cases, patients developed postoperative complications, as follows: wound suppuration in three cases, haemothorax – in two, two pleurisy – in six, and disorders of the abdominal organs – in five. Postoperative complications developed in six of the eight cases of gunshot injuries. Severe intrapleural bleeding, shock, and liver injuries had significant influence (P<0.05), relevant to the development of postoperative complications (Table 4).


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  		Table 4. Risk factors of postoperative complications in patients with penetrating DI

 
3.5.2. Blunt DI
Postoperative complications developed in 11 (50.0%) of the patients. In four cases, the complication was adult respiratory distress syndrome, in two – pneumonia, in four – pleurisy, in two – polyorganic insufficiency, and in two – disorders of the abdominal organs. Multiple fractures of the chest bones, and severe intraabdominal bleeding, caused by associated liver and spleen injuries, had significant influence (P<0.05), relevant to the development of postoperative complications (Table 5).


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  		Table 5. Risk factors of postoperative complications in patients with blunt DI

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
The diaphragm is the most important respiratory muscle. However, it was not actually the blunt or penetrating DI that caused danger to a patient's health and even life, but rather, their ensuing consequences. From this point of view, damage to the diaphragm, as a partition-wall located between abdominal and chest cavities, is of greater importance than its respiratory dysfunction. This is one of the substantial clinical features of DI, especially in cases of blunt TAT. The diaphragm is in a constant state of movement, therefore, stab or gunshot wounds and blunt ruptures almost never heal without surgical repair.

Until the most significant consequences of DI, TDH and its complications, had developed, DI displayed almost no specific early clinical symptoms or X-ray signs. To diagnose DI before the development of complications, it is first necessary to bear in mind the possibility of this rather rare injury [14–17]. DI are sometimes misdiagnosed, because the generally violent symptoms of associated injuries initially disguise the slight clinical signs of them, and not because surgeons pay less attention to this pathology. A chest X-ray examination, which is taken with the patient in a supine position, may be non-informative, and possibly, erroneous [18]. Non-specific X-ray signs, such as the high position of the diaphragmatic cupola, were found in 42% of the patients, and absolutely normal chest roentgenogram resulted for 15% of the patients in whom DI was later discovered [3]. Therefore, clinical and X-ray examinations, as diagnostics methods, are not reliable. Instead, effort must be made to inspect the diaphragm visually. This can be accomplished during the surgical revision of the penetrating chest wall wounds, and by thoracoscopy and/or laparoscopy [1,7,8]. In cases when an urgent thoracotomy or laparatomy has been performed, a thorough examination of the diaphragm is mandatory [15].

DI belongs to the category of diseases for which urgent surgical intervention is the required treatment [9]. The choice of surgical approach (thoracotomy, laparotomy, or both) depends greatly on associate injuries and trauma related syndromes. The part of the body (abdomen or chest) in which pathologic processes are the most threatening must be first explored [20]. Application of these tactics in the treatment of DI calls for urgent surgical intervention that is more often started with laparotomy [4,9,15,16,19], rather than thoracotomy [1,5,20].


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
References
 

  1. If all subjects who suffered from TAT could have been alive when admitted to the hospital, the incidence rate of penetrating and blunt DI among patients would have been 3.4%, and 2.1%, respectively.
  2. The danger to the health or even life of a patient is caused, not by DI in and of themselves, but by their consequences, namely TDH, and associated injuries.
  3. The effectiveness of DI treatment is determined by aggressive and purposeful surgical diagnostics and urgent intervention.


   Footnotes
 
Presented at the 7th Conference of the European Society of Thoracic Surgeons, October 21–23, 1999.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

  1. Bagdonas E., Rubikas R., Vileinskas A., Kunigèlis G., Bagdonas R., Gulbinas A. Diaphragmatic injuries and their treatment. Acta Med Lithuan 1997;4:86-89.
  2. Buckman R., Piano G., Soutter I., Ramzy A., Militelli P. Major bowel and diaphragmatic injuries associated with blunt spleen or liver rupture. J Trauma 1988;28:1317-1320.[Medline]
  3. Guth A., Pachter H., Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995;170:5-9.[Medline]
  4. Madden M., Paull D., Finkelstein J., Goodwin C., Marzulli V., Yurt R., Sires G. Occult diaphragmatic injury from stab wounds to the lower chest and abdomen. J Trauma 1989;29:292-297.[Medline]
  5. Abakumov M., Abdullaev S., Vladimirova E., Dzhagraev K. Diapragmatic ruptures in combined injuries to the chest and abdomen. Vestnik Khirurgii Im II Grek 1991;146:64-68 (in Russian).
  6. Colliver C., Oller D., Rose G., Brewer D. Traumatic intrapericardial diaphragmatic hernia diagnosed by echocardiography. J Trauma 1997;42:115-116.[Medline]
  7. Horstmann O., Neufang T., Post S., Stephan H., Becker H. Laparoskopische Diagnostik und Therapie geschlossener traumatischer Zwerchfellrupturen. Chirurg 1996;67:744-747.[Medline]
  8. Jackson A., Ferreira A. Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wound of the left lower chest: a preliminary report. Injury 1976;7:213-217.[Medline]
  9. Kearney P., Rouhana S., Burney R. Blunt rupture of the diaphragm: mechanism, diagnosis, and treatment. Ann Emerg Med 1989;18:1226-1330.
  10. Shah R., Sabanathan S., Mearns A., Choudhury A. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444-1449.[Abstract/Free Full Text]
  11. Van Vugt A., Schoots F. Acute diaphragmatic rupture due to blunt trauma; retrospective analysis. J Trauma 1989;29:683-686.[Medline]
  12. Lee W., Chen R., Fang J., Wang C., Chen H., Chen S., Hwang T., Jeng L., Jan Y., Wang C., Chen M., Lou C., Wang J., Lin J. Rupture of the diaphragm after blunt trauma. Eur J Surg 1994;160:479-783.[Medline]
  13. Van der Werken C., Lubbers E., Goris R. Rupture of the diaphragm by blunt trauma as a marker of injury severity. Injury 1984;15:149-152.
  14. Flancbaum L., Morgan A., Esposito T., Cox E. Non-left sided diaphragmatic rupture due to blunt trauma. Surg Obstet Gyneacol 1985;161:266-269.
  15. Athanassiadi K., Kalavrouziotis G.M., Vernikos P., Skrekas G., Pultsidi A., Bellenis I. Blunt diaphragmatic rupture. Eur J Cardio-thorac Surg 1999;15:469-474.[Abstract/Free Full Text]
  16. Arak T., Solheim K., Pillgram-Larsen J. Diaphragmatic injuries. Injury 1997;28:113-117.[Medline]
  17. Pfannschmidt J., Seiler H., Bottcher H., Karadiakos N., Neisterkamp B. Zwerchfellrupturen: Diagnostik-Therapie-Ergebnisse. Erfahrungen bei 64 Patienten. Aktuelle Traumatol 1994;24:48-51.[Medline]
  18. Macfarlane R., Pollard S. Diaphragmatic rupture following closed injury – a pitfall of supine chest radiology. Injury 1987;18:409-410.[Medline]
  19. Adamthwaite D. Diaphragmatic hernia presenting itself as a surgical emergency. Injury 1984;15:367-369.[Medline]
  20. Hirshberg A., Wall M., Allen M., Mattox K. Double jeopardy: thoracoabdominal injuries requiring surgical intervention in both chest and abdomen. J Trauma 1995;39:225-231.[Medline]



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