Diagnosis Of Diaphragmatic Injury Research Articles

A Retrospective Study of Traumatic Diaphragmatic Hernia in Rajasthan

Introduction: Diaphragmatic injuries occur in 3.9 % of chest injuries. Traumatic diaphragmatic hernia usually undergo unrecognized. Diagnosis of diaphragmatic injuries is usually difficult. Materials and Methods: The records of patients who got operated for traumatic diaphragmatic hernia in the Department of Cardio- Thoracic and Vascular Surgery at SMS Hospital, Jaipur between July 2012 to July 2019 were referred. 39 patients underwent surgery for diaphragmatic hernia. From records history, age, sex, symptoms, signs, chest X-ray finding, operative approach for repair, operative course and outcome were recorded. Results: From 2012 July to 2019 July, 39 patients were operated by thoracotomy for traumatic diaphragmatic injury of which 29 were males and 10 were females. The oldest patient was 60 years old and the youngest was 12 years old. The cause of rupture of diaphragm was blunt abdominal trauma in 30 cases, penetrating chest trauma was seen in 9 cases. 33 cases gave history of road traffic accidents, 6 had fallen from height. Left sided tear was seen in 35 cases whereas 4 patients had right sided rupture. Most common symptom was difficulty in breathing seen in 34 cases. Reduced air entry was seen in 39 cases. The diagnosis of diaphragmatic hernia was made on the basis of history, clinical examination of chest X-ray with ryles tube in situ in 36 cases, whereas 3 case required CECT. Conclusion: Traumatic diaphragmatic hernia requires high index of suspicion for diagnosis, investigation most commonly chest x ray with ryles tube. It is more common in males and usually left sided. Early and prompt surgical repair by thoracotomy is the treatment of choice. The following core competencies are addressed in this article: Patient care and Procedural skills, Medical knowledge, and System-based practice.

Can invasive diagnostic methods be reduced by magnetic resonance imaging in the diagnosis of diaphragmatic injuries in left thoracoabdominal penetrating injuries?

Aim:In this study, we aimed to investigate the effect of magnetic resonance imaging (MRI) in detecting diaphragmatic injury by comparing preoperative computed tomography (CT) and MRI imaging results with diagnostic laparoscopy/thoracoscopy results in patients with left thoracoabdominal penetrating injury. We investigated whether MRI reduces the rate of unnecessary surgery by examining its sensitivity and specificity.Materials and Methods:Patients with left thoracoabdominal penetrating injuries who applied to the Emergency Surgery Unit of Istanbul University Istanbul Faculty of Medicine between November 2017 and December 2020 were evaluated. Patients who underwent emergency surgery, who could not undergo MRI or CT for any reason or who could not be operated on were excluded from the study. Preoperative MRI and CT images of patients who underwent diagnostic laparoscopy/thoracoscopy due to left thoracoabdominal injury in our clinic were evaluated retrospectively by a radiologist who did not know the surgical results. MRI results of the cases were compared with surgical findings and CT images.Results:A total of 43 (41 males, mean age: 31, range: 15–57) patients were included in the study. The most common physical examination finding was lateral injury. The diaphragmatic injury was detected in 13 (30%) cases during surgical interventions. Laparoscopic repair was performed in 11 (84%) cases and thoracoscopic repair was performed in 2 (15%) cases with diaphragmatic injuries. MRI images of 14 (32%) cases were found to be compatible with diaphragmatic injury, in 1 of them no injury was observed during surgical intervention. According to these data, the sensitivity of MRI was calculated as 100%, specificity 94%, positive predictive value 86%, and negative predictive value 100%. The mean hospital stay was 6 days (1–30) in all cases.Conclusion:In our study, MRI was found to have high specificity and sensitivity in detecting diaphragmatic injuries. The number of negative laparoscopy/thoracoscopy can be reduced by performing surgical intervention only in cases with positive or suspected diaphragmatic injury on MRI. Results should be supported by conducting new studies with larger case series with normal MRI findings and long follow-ups.

Missed traumatic diaphragmatic hernia and literature review

The diagnosis of traumatic diaphragmatic rupture owing to blunt or penetrating injuries may be missed in acute case presentations. Mortality in patients with acute blunt injuries is highest in those with associated organ damage. The diagnosis of diaphragmatic injuries may be missed because of delayed case presentation or delayed diagnosis. Diaphragmatic injuries should be suspected in all patients with blunt or penetrating injuries of the chest and abdomen. Special care must be taken during the insertion of intercostal drains to the chest in order to avoid iatrogenic injury to the stomach, bowel and other organs, particularly in cases when a missed diaphragmatic injury cannot be excluded. We share in this article our experiences with two cases of missed traumatic diaphragmatic injuries, one on the left and the other on the right side.

Povrede dijafragme - dijagnostika i terapija

Traumatic diaphragmatic injury (DI) is a unique clinical entity that is usually occult and can easily be missed. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of DI challenging to the trauma surgeons. Diaphragmatic injury may result within closed, blunt thoracoabdominal trauma or acute, penetrating thoracic, abdominal and thoracoabdominal trauma. Signs and symptoms of diaphragm injury are not specific and often remain undetected due to serious associated injuries, which distract surgeons' attention, complicating the diagnosis. Since it is not that frequent, little attention has been paid. For all above-mentioned, preoperative diagnosis is established with less than 1/2 of patients, with 44% on autopsy or intraoperatively accidentally, and in about 14% it was delayed even for several years. Many authors have tried, and Grimes has succeeded in introducing three phases of diaphragmatic injury describing acceptable system of detecting this organ injury: Acute phase - the diaphragmatic rupture, usually missed, because symptoms of associated injuries of organs prevail; Latent phase - with viscera partially protruding through diaphragmatic opening. It is characterised by mild symptoms of discomfort and uneasiness in hypohondrium and hemithorax of the injured side. Signs of dyspnoea and orthopnoea are moderate, and there might be a radiograph after chest X-ray; Obstructive phase - where the abdominal organs penetrate into the thorax and symptoms resulting from an obstruction or ischemia occur. It is usually characterised by Borchardt's Triad (strong epigastric pain, vomiting and the inability to pass a nasogastric tube), with X-ray indicating mediastinum shift, with obvious penetration of abdominal organs into the pleural space. Any diaphragmatic injury requires operational treatment, since this organ's injuries cannot spontaneously heal. Even injuries of smaller dimensions must be sutured to prevent outcome such as diaphragmatic hernia and its consequences.

Double Blow Injury: Diaphragmatic Rupture with Gastric Perforation Following Blunt Trauma

Diaphragmatic injury is an unusual life threatening complication of blunt trauma abdomen. However, a double blow injury occurring simultaneously such as diaphragmatic hernia and gastric injury is a rare injury. The association of gastric perforation along with diaphragmatic injury increases the mortality as well as morbidity manifold as compared to an isolated diaphragmatic injury. Traumatic diaphragmatic injury has variable clinical presentation ranging from pain in abdomen to respiratory distress and pneumonia. Preoperative diagnosis of diaphragmatic injury is quite demanding and often it goes undetected only to be found later intraoperatively. Although chest X-ray is still the best screening imaging modality to detect the diaphragmatic hernia but occasionally, especially for right-sided diaphragmatic injury, computed tomography and magnetic resonance imaging may be required to detect it in early stage. Here, we report a case of diaphragmatic hernia with gastric perforation sustaining blunt trauma in an 18 years old, young adult. Only a few cases of double blow injury with perforation of the diaphragm and stomach are reported in the literature. We aim to report this case because a prompt intervention with high degree of suspicion is the key to success in managing diaphragmatic hernia with gastric perforation following blunt trauma injury to the abdomen.

Forensic, clinical and anatomical aspects of diagnosising diaphragmatic injuries in stab wounds

To improve the quality of clinical and forensic examination and diagnosis of diaphragmatic injury (DI) from stab wounds by defining the boundaries of the thoraco-abdominal region and the topographic and anatomical characteristics of thoracoabdominal stab wounds. Based on the results of forensic medical examinations of 81 corpses with stab wounds, the clinical and anatomical characteristics of thoraco-abdominal stab wounds were noted; and in anatomical dissections of 90 cadavers, the boundaries of the intercostal spaces and costophrenic recess were modeled. The boundaries of the thoraco-abdominal region, and the location of stab wounds that make the probability of DI particularly high (10-50%) were clarified. A method for diagnosing DI was developed. The method was used to identify DI in 81 out of 411 victims with penetrating stab wounds to the chest and abdomen. The results of the study prove the feasibility of using computed tomography in the examination of living persons with a wound in the thoracoabdominal region. This study can assist in determining the features of a wound channel, in providing a correct assessment of the damage, and in the identification of undiagnosed DI.

Tension fecopneumothorax secondary to unrecognized delayed traumatic diaphragmatic hernia

Traumatic diaphragmatic hernia is an uncommon but severe problem that is usually seen in patients suffered from blunt or penetrating thoracoabdominal injuries. Despite advances in modern technology, 30–50% of traumatic diaphragmatic ruptures are missed on initial presentation. We report a case of tension fecopneumothorax secondary to an undiagnosed delayed traumatic diaphragmatic hernia in a patient, who sustained blunt trauma chest 15 years back. This case is being presented to emphasize readers that, the diagnosis of diaphragmatic injuries is challenging and requires a high index of clinical suspicion, late presentations are associated with increased morbidity and mortality.

Pitfalls in diagnosis of diaphragmatic tear

Traumatic diaphragmatic injury is a life threatening and an occult clinical entity which can be easily missed in diagnosis. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of Diaphragmatic Injury is challenging to the surgeons. Here we report a case of young adult male with poly trauma, whose initial diagnosis revealed multiple rib fractures on right side and right haemothorax and normal left pneumothorax. After intercostal drainage was placed on right side, left diaphragmatic tear with bowel contents in left lung cavity was revealed. He was successfully managed surgically. Hence we report this case to emphasize that a high clinical index of suspicion is needed to diagnose, effectively manage diaphragmatic rupture even with a remote history of high-velocity injury.

Fractured Ribs and the CT Funky Fat Sign of Diaphragmatic Rupture.

Traumatic diaphragmatic rupture remains a diagnostic challenge for both radiologists and surgeons. In recent years, multidetector CT has markedly improved the diagnosis of diaphragmatic injury in polytrauma patients. Herein, we describe two cases of subacute presentation of traumatic diaphragmatic rupture from a penetrating rib fracture and subsequent intrathoracic herniation of omental fat, representing the CT “funky fat” sign.

Late Gastric Incarceration 20 Years after Penetrating Chest Trauma

The diagnosis of diaphragmatic injury in trauma patients is a challenge for surgeons. Misdiagnosis is common and can only be corrected when patients present with symptoms of diaphragmatic hernia. We report a rare case of delayed traumatic diaphragmatic hernia masquerading as empyema 20 years after lower chest penetrating trauma. The herniated stomach was found intraoperatively. Delayed traumatic diaphragmatic hernia should always be suspected in patients with trauma that may have occurred many years ago.

Thoracoscopy for Trauma

Thoracoscopy has numerous applications for both diagnosis and treatment in thoracic trauma. It is excellent for the diagnosis of diaphragmatic injuries, mediastinal evaluation, and the assessment of persistent air-leak. It offers therapeutic intervention for diaphragmatic lacerations, thoracic bleeding in stable patients, evacuation of residual hemothorax, air-leaks, and the prevention and treatment of empyema. Judiciously applied, it is a powerful tool in the armamentarium of the trauma surgeon.

Treating traumatic injuries of the diaphragm

Traumatic diaphragmatic injury (DI) is a unique clinical entity that is usually occult and can easily be missed. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of DI challenging to the trauma surgeons. An emergency laparotomy and thorough exploration followed by the repair of the defect is the gold standard for the management of these cases. We report a case of blunt DI in an elderly gentleman and present a comprehensive overview for the management of traumatic injuries of the diaphragm.

Traumatic diaphragmatic injuries in children: do they really mark the severity of injury? Our experience

Diaphragmatic injuries have been reported to be a predictor of serious associated injuries in trauma and a marker of severity. Because of its rarity in children, the diagnosis is often delayed for months and years, due to overshadowing injuries. Perhaps due to the elasticity of their tissues, traumatic diaphragmatic rupture is uncommon in children. The problem remains a challenging clinical entity and the description of such type of injuries in children remains scarce in the literature. Most of the cases are described along with associated injuries; presence of isolated diaphragmatic injuries in children is unusual. The present study highlights the presentation, diagnosis and management of all of the cases admitted with traumatic diaphragmatic injuries in a single pediatric surgical center. We retrospectively studied eight children admitted to our center with a diagnosis of diaphragmatic injury following trauma during a period of 5 years (2003-2008). Relevant information regarding the mode and pattern of injuries were noted in all cases. Type of injury and surgical intervention and outcome of patients were evaluated. Mean age of presentation was 6.8 years (range 2-12 years). Seven patients were males, while one patient was female. Seven patients had a history of blunt trauma abdomen some time back. Only one patient had acute presentation with respiratory distress following road traffic accident, rest of the patients had no associated grievous injury at the time of presentation. One patient presented with features of acute obstruction. All patients could be diagnosed preoperatively and surgical intervention was performed in all cases. The patients recovered well and there was no mortality. Diaphragmatic injuries in children are rare. They are usually associated with other severe injuries; however, isolated diaphragmatic injuries occur more frequently in children than adults. A high index of clinical suspicion supported by prompt radiological tests is needed to diagnose these injuries in patients who otherwise have no associated grievous injuries.

Factors Affecting Mortality and Morbidity After Traumatic Diaphragmatic Injury

We review our 11-year experience of treating diaphragmatic injury (DI), to identify the factors determining mortality and morbidity. We analyzed the effects of demographic characteristics, type of injury (blunt or penetrating), number of injured organs, injury severity score (ISS), revised trauma score (RTS), Glasgow coma score, and intensive care unit and hospital stay, on complications and mortality, in 51 patients treated for DI between January 1995 and December 2005. Twenty-six (51%) patients suffered blunt injury and 25 (49%) suffered penetrating injury. The left diaphragm was injured in 40 (78%) patients, the right in 10 (19%), and both sides in 1 (2%). Only three (5.8%) patients had no concomitant injury. The diagnosis was made by the findings of laparotomy on 34 patients (65%), preoperative chest X-ray on 13 (25%), computed tomography on 2 (3.9%), and laparoscopy on 2 (3.9%). Complications developed in 23 (44%) patients and overall mortality was 19.6% (10/51). An ISS > 13 was found to be an independent prognostic factor for morbidity, whereas an RTS < or = 11, age > or = 48 years, and a major postoperative complication were independent prognostic factors for mortality. Establishing a preoperative diagnosis of DI is still problematic. Aggressive treatment and close monitoring of patients with an ISS > 13, an RTS < or = 11, an age > or = 48 years, or a postoperative complication may decrease morbidity and mortality.

Acute tension pneumothorax due to perforation of misdiagnosed traumatic diaphragmatic gastric hernia

A traumatic diaphragmatic hernia is a well-known complication following blunt or penetrating injuries to the diaphragm. However, the diagnosis may be delayed because of a lack of symptoms. Diagnosis of diaphragmatic injury is a great challenge to the surgeon, who must first suspect the diagnosis and then as soon as possible, with the radiologist, try to prove or disprove its existence. A tension pneumothorax with mediastinal shift resulting from the intrathoracic perforation of the stomach has only rarely been noticed. We report a 52-year-old man with a tension pneumothorax and a shift of his entire mediastinum resulting from an intrathoracic perforation of the stomach, after a blunt trauma of the chest and a misdiagnosed traumatic diaphragmatic hernia.

Traumatic diaphragmatic injuries: spectrum of radiographic findings.

Traumatic diaphragmatic injuries are usually caused by blunt trauma or penetrating injuries. The diagnosis may be delayed due to confusing clinical and radiographic findings. According to the results of a review of 25 cases, the diagnosis of diaphragmatic injury is more often delayed and requires more imaging studies in cases of blunt trauma than in cases of penetrating injury. Blunt injury is indicated by asymmetry of a hemidiaphragm or changing diaphragmatic levels, abdominal contents within the chest, diaphragmatic paresis, unexplained hemothorax, or multiple upper abdominal injuries. Penetrating injury is indicated by hemothorax or a missile or blade trajectory through or near the diaphragm. Usually, plain radiography shows initial evidence of traumatic diaphragmatic injury and prompts confirmatory imaging, which includes computed tomography, magnetic resonance imaging, barium studies, fluoroscopy, nuclear medicine, and ultrasound. Nevertheless, the diagnosis of traumatic diaphragmatic injury may be elusive and often can be made only during exploratory surgery.

Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries

Background: Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury. Patients and methods: Hemodynamically stable patients admitted to a level I trauma center with blunt or penetrating injury to the lower chest or abdomen underwent VATS and subsequent celiotomy under the same general anesthetic. Intraoperative thoracoscopic findings were blinded to the abdominal surgeons. Results: Twenty-six patients were enrolled in the study over a 12-month period. Diaphragmatic injuries were identified in 8 patients (31%). Videothoracoscopy identified all eight injuries in these patients. Six of the 8 patients (75%) with diaphragmatic injuries sustained associated injury to intrathoracic or intra-abdominal organs. There was no mortality and no procedure-related morbidity. There were no missed injuries in patients who underwent VATS. Conclusions: Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.

PROSPECTIVE EVALUATION OF THORACOSCOPY FOR DIAGNOSING DIAPHRAGMATIC INJURY IN THORACOABDOMINAL TRAUMA: A PRELIMINARY REPORT

Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.

Traumatic injury to the diaphragm: timely diagnosis and treatment.

Traumatic injury to the diaphragm is a relatively uncommon injury with potential for considerable morbidity if the diagnosis is delayed or missed. This review of cases of traumatic diaphragmatic injury was undertaken in order to emphasize methods and timing of diagnosis and treatment. From 1986 through 1990, 43 cases of traumatic diaphragmatic injury were admitted to the trauma unit at Sunnybrook Health Sciences Centre, for an incidence of 2% of all new multiple trauma admissions. All patients were evaluated and treated by a dedicated trauma team. The left hemidiaphragm was injured in 32 patients, the right hemidiaphragm was injured in eight cases, and the injury was bilateral in three patients. Thirty-four patients had blunt trauma. The mean Injury Severity Score for all patients was 32. The diagnosis of diaphragmatic injury was made radiologically in 21 cases and at surgery in 22 cases. The diagnosis in all cases with penetrating trauma was made at the time of surgery. The interval between injury and definitive surgery was less than 12 hours in 39 of 43 patients. The diagnosis of diaphragmatic injury was delayed by more than 12 hours in only one patient. The other three patients were diagnosed soon after injury but their definitive surgery was delayed for other reasons. Surgical repair of the diaphragm was performed via laparotomy in 40 of 43 cases. Only one patient was repaired in a delayed fashion by thoracotomy for thoracic complications. A clear contrast can be drawn between blunt injuries and penetrating trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Blunt and Penetrating Diaphragmatic Injuries with or without Herniation of Organs into the Chest

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eighty-five patients with penetrating injury (Group 1) and 9 with blunt injury (Group 2) required emergency laparotomy. In the remaining 15 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 18 hours to 15 years (mean, 8 months) after injury. The vast majority of the Group 1 and all Group 2 patients had injury to other organs, and the diagnosis of the diaphragmatic injury was made in almost all of them during the emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or with an upper gastrointestinal series or barium enema. All diaphragmatic injuries were repaired primarily except one which was repaired with Prolene mesh. Four of the Group 1 patients died, a mortality of 2.2%, and 2 of the Group 2 patients died, a mortality of 22.2%. All Group 3 patients recovered. This study suggests that diaphragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen and particularly of the epigastrium and lower chest. The presence of such an injury should be excluded before the termination of the exploratory procedure. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm or lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.