Traumatic Diaphragmatic Rupture Research Articles

Travmatik Diafragma Rüptürü Olan Bir Vakada Rastlantısal Tespit Edilen Perikardial Rüptür ve Kalp Herniasyonu

Pericardium and heart injuries are rare situations accompanying to traumatic diaphragmatic ruptures. We diagnosed diaphragmatic rupture for a 42 year old man after a traffic accident

Delayed Traumatic Diaphragmatic Hernia With Bacterial Pleuritis

Thoraco-abdominal blunt trauma may cause traumatic diaphragmatic hernia. Here, we report a case of delayed traumatic diaphragmatic rupture with herniation of multiple viscera along with bacterial pleuritis without perforation or necrosis. A 72-year-old man presented with severe left-sided chest pain and dyspnea following a fall in the bathroom on the previous day; he had hit the left side and back of the chest against a faucet. Computed tomography (CT) revealed pneumoderma, mediastinal emphysema, pneumothorax, and fractures of the 8th–11th left ribs. We diagnosed traumatic pneumothorax, which was treated by a thoracostomy tube inserted into the pleural space. Approximately 6 months later, he presented again with fever (39.2°C), dyspnea, and coughing. The white blood cell count and C-reactive protein were elevated at 20.3 × 103/μL and 28.7 mg/dL, respectively. A CT scan revealed left-sided pleural effusion and diaphragmatic hernia. Thoracocentesis was performed for the pleural effusion, and bacterial cultivation tests revealed Bacteroides fragilis; therefore, antibiotics were administered for 3 weeks. Subsequently, diaphragmatic hernia repair was performed. Laparotomy via a left subcostal incision revealed a defect measuring 60 × 60 mm; this was repaired with uninterrupted absorbable sutures without using a hernia mesh to avoid infection. The postoperative course was uneventful, and no recurrence was noted at the 1-year follow-up. We repaired delayed traumatic diaphragmatic rupture with herniation of multiple viscera by simple suturing without using a hernia mesh following the treatment of associated bacterial pleuritis.

Characterisation of human diaphragm at high strain rate loading

Motor vehicle crashes (MVC׳s) commonly results in life threating thoracic and abdominal injuries. Finite element models are becoming an important tool in analyzing automotive related injuries to soft tissues. Establishment of accurate material models including tissue tolerance limits is critical for accurate injury evaluation. The diaphragm is the most important skeletal muscle for respiration having a bi-domed structure, separating the thoracic cavity from abdominal cavity. Traumatic rupture of the diaphragm is a potentially serious injury which presents in different forms depending upon the mechanisms of the causative trauma. A major step to gain insight into the mechanism of traumatic rupture of diaphragm is to understand the high rate failure properties of diaphragm tissue. Thus, the main objective of this study was to estimate the mechanical and failure properties of human diaphragm at strain rates associated with blunt thoracic and abdominal trauma. A total of 23 uniaxial tensile tests were performed at various strain rates ranging from 0.001–200s−1 in order to characterize the mechanical and failure properties on human diaphragm tissue. Each specimen was tested to failure at one of the four strain rates (0.001s−1, 65s−1, and 130s−1, 190s−1) to investigate the effects of strain rate dependency. High speed video and markers placed on the grippers were used to measure the gripper to gripper displacement. Engineering stresses reported in the study is calculated from the ratio of force measured and initial cross sectional area whereas engineering strain is calculated from the ratio of the elongation to the undeformed length (gauge length) of the specimen.The results of this study showed that the diaphragm tissues is rate dependent with higher strain rate tests giving higher failure stress and higher failure strains. The failure stress for all tests ranged from 1.17MPa to 4.1MPa and failure strain ranged from 12.15% to 24.62%.

Secondary Spontaneous Rupture of the Diaphragm in a Child after Blunt Chest Trauma

Traumatic diaphragmatic rupture (TDR) is very rare in the pediatric age group. Because of its rarity and its coexistence with more injuries, the diagnosis is often delayed. Very little has been written about this condition in the pediatric age group. TDR, while uncommon, should be considered in cases of blunt thoracic trauma. All patients should undergo meticulous examination preoperatively. The clinical presentation and importance of making an accurate diagnosis and surgery is highlighted. We report a case of secondary spontaneous traumatic left-sided diaphragmatic rupture in a child that was managed by delayed surgical repair.

A Case Report on Diaphragmatic Rupture, in the Visceral Surgery of Hospital of Conakry, Guinea

The aim of this case report is to share our experience in the management of this this rare case of traumatic diaphragmatic rupture in the visceral surgery department of the Hospital of Conakry. Traumatic diaphragmatic rupture is an unfamiliar diagnosis to make and exceptionally seen in some cases of high velocity injuries which involve the abdomen. The high energy from blunt trauma transmitted across the abdomen gives rise to an excessively high pressure in the abdominal cavity which causes shearing of the diaphragmatic muscle. It is indeed considered as a surgical emergency as impaired diaphragmatic movement has a big impact on ventilation and oxygenation of blood. The delay in making appropriate diagnosis due to the lack of overt clinical signs relating to this type of injury accounts for the high mortality rates reaching 31%. We are reporting on a case concerning a 28-year old male patient who was admitted at the department of visceral surgery at the National Hospital of Donka, Conakry, Guinea, for emergency evaluation and treatment of a left sided traumatic diaphragmatic rupture associated with eventration of viscera into the thoracic cavity and contusion of the ascending colon. The mechanism of rupture was determined as a force vector directed frontally and was transmitted across the diaphragmatic wall. A clinical diagnosis was made and confirmed by radiological imaging preoperatively. Prompt surgical intervention was provided within the 1^st 24 hours from the time of admission. No complications had been encountered during the post-operative recovery period. The best way to evaluate traumatic diaphragmatic rupture in a patient is through a well-devised systematic approach. It is not advised to perform lengthy imaging tests in a hemodynamically unstable patient and thus, compromising the success of the surgical outcome.

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.

The Use of Biological Meshes in Diaphragmatic Defects - An Evidence-Based Review of the Literature.

The widespread use of meshes for hiatal hernia repair has emerged in the era of laparoscopic surgery, although sporadic cases of mesh augmentation of traumatic diaphragmatic rupture have been reported. The indications for biologic meshes in diaphragmatic repair are ill defined. This systematic review aims to investigate the available evidence on the role of biologic meshes in diaphragmatic rupture and hiatal hernia repair. Limited data from sporadic case reports and case series have demonstrated that repair of traumatic diaphragmatic rupture with biologic mesh is safe technique in both the acute or chronic setting. High level evidence demonstrates short-term benefits of biologic mesh augmentation in hiatal hernia repair over primary repair, although adequate long-term data are not currently available. Long-term follow-up data suggest no benefit of hiatal hernia repair using porcine small intestine submucosa over suture repair. The effectiveness of different biologic mesh materials on hernia recurrence requires further investigation.

Patient care report for the stabilisation of a cat with a traumatic diaphragmatic rupture

Diaphragmatic ruptures in cats are often seen following trauma and can cause severe respiratory distress. This article reflects on the author's experience of providing emergency nursing care to a 2-year-old, domestic short hair cat, with a traumatic diaphragmatic rupture. In order to provide effective nursing care it is essential for the veterinary nurse to understand the effects of shock in the feline patient. Creating a protocol for the management of the dyspnoeic trauma cat could facilitate a more efficient treatment plan, allowing for available monitoring equipment to be fully utilised. If advanced monitoring techniques are not available, a successful patient outcome is still achievable with basic nursing skills and a good underpinning knowledge of the emergency and critical patient.

The feasibility and efficacy of laparoscopic repair for chronic traumatic diaphragmatic herniation: introduction of a novel technique with literature review

Traumatic diaphragm rupture is a rare trauma that is easily overlooked. A missed diagnosis would result in chronic traumatic diaphragmatic herniation (CTDH). Surgical repair is the standard treatment that is conventionally performed by laparotomy or thoracotomy. Laparoscopic repair has been reported, but its efficacy remains controversial. In this study, we present our novel technique and experience of laparoscopic repair of CTDH and analyze the feasibility and effectiveness of this procedure. We conducted a prospective collection with retrospective review of patients with CTDH treated at Chang Gung Memorial Hospital, Taiwan, from 2000 to 2013. The demographic characteristics, surgical procedure, perioperative results, length of hospital stay (HLOS) and follow-up were record and analyzed. There were 114 patients with traumatic diaphragm hernia, and 24 of them had CTDH with a mean age of 54.9±13.3years. The HLOS was 15.08±8.17days. Regarding the surgical method used, 19 patients had open surgery, and 5 patients underwent laparoscopic surgery. The demographic distribution, trauma mechanism, location and size of CTDH were comparable. In the laparoscopic group, the patients had a shorter median HLOS (6days) than in the open surgery group (16days; p=0.002). There was no mortality or recurrence in both groups. In this study and literature review, patients had laparoscopic repair with a smooth recovery. Laparoscopy provides good surgical exposure, allowing easy repositioning of the herniated content and a smooth repair of the defect without the morbidity of laparotomy. For CTDH, with caution, we can apply this technique with an acceptable result.

Diaphragmatic Hernia in an isolated severe head injury patient: An accidental finding

Blunt traumatic rupture of diaphragm is uncommon in an isolated severe head injury patient and usually seen in polytrauma patients. Due to poor neurological status, diagnosis is often difficult and leads to increase in morbidity and mortality. We report a case of diaphragmatic hernia in a 25 year old male having isolated severe head injury sustained in a road traffic accident, diagnosed two days later on routine chest X-ray. Ryle’s tube shadow in left lower lung field that give raise to suspicion of diaphragmatic hernia and CT scan confirms the diagnosis. A high index of suspicion is required for early diagnosis and minimizes the morbidity and mortality associated with it.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre

PurposeTraumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre. MethodsWe used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed. ResultsOf the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury. ConclusionsThe detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

A rare case of traumatic diaphragmatic rupture with delayed presentation

Traumatic injuries of the diaphragm is an entity of difficult diagnosis, it is important because of the frequency and severity of associated injuries, the difficulties in reaching the diagnosis require an aggressive search in patients at risk. We report the case of a patient with blunt trauma with right diaphragmatic rupture that required urgent surgical treatment. Blunt trauma can cause substantial diaphragmatic rupture. It must have a high index of suspicion for diaphragmatic injury in patients, victims of vehicle collisions and in patients with severe thoracoabdominal trauma.

Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries

PurposeTraumatic diaphragmatic rupture (TDR) needs early diagnosis and operation. However, the early diagnosis is usually difficult, especially in the patients without diaphragmatic hernia. The objective of this study was to explore the early diagnosis and treatment of TDR. MethodsData of 256 patients with TDR treated in our department between 1994 and 2013 were analyzed retrospectively regarding to the diagnostic methods, percentage of preoperative judgment, incidence of diaphragmatic hernia, surgical procedures and outcome, etc. Two groups were set up according to the mechanism of injury (blunt or penetrating). ResultsOf 256 patients with a mean age of 32.4 years (9–84), 218 were male. The average ISS was 26.9 (13–66); and shock rate was 62.9%. There were 104 blunt injuries and 152 penetrating injuries. Preoperatively diagnostic rate was 90.4% in blunt injuries and 80.3% in penetrating, respectively, P < 0.05. The incidence of diaphragmatic hernia was 94.2% in blunt and 15.1% in penetrating respectively, P < 0.005. Thoracotomy was performed in 62 cases, laparotomy in 153, thoracotomy plus laparotomy in 29, and combined thoraco-laparotomy in 12. Overall mortality rate was 12.5% with the average ISS of 41.8; and it was 21.2% in blunt injuries and 6.6% in penetrating, respectively, P < 0.005. The main causes of death were hemorrhage and sepsis. ConclusionsDiagnosis of blunt TDR can be easily obtained by radiograph or helical CT scan signs of diaphragmatic hernia. For penetrating TDR without hernia, “offside sign” is helpful as initial assessment. CT scan with coronal/sagittal reconstruction is an accurate technique for diagnosis. All TDR require operation. Penetrating injury has a relatively better prognosis.

Intrathoracic Kidney after Blunt Abdominal Trauma: A Case Report and Review of the Literature.

Abdominal trauma is responsible for most genitourinary injuries. The incidence of renal artery injury and intrathoracic kidney is quite low in patients who present with blunt trauma experiencing damage. There are four defined etiologies for intrathoracic kidney, which include real intrathoracic ectopic kidney, eventration of the diaphragm, congenital diaphragmatic herniation, and traumatic diaphragmatic rupture. The traumatic intrathoracic kidney is an extremely rare case. We presented intrathoracic kidney case after traumatic posterior diaphragmatic rupture.

A Case of Traumatic Hepatothorax

Diaphragmatic injury from trauma is potentially fatal, and unfortunately initial diagnosis of traumatic diaphragmatic rupture is often missed in the acute setting. Radiographs may not show immediate herniation of abdominal contents indicating a defect in the diaphragm, and computed tomography is not always performed on trauma patients presenting without signs of abdominal pathology. Right-sided rupture occurs much less frequently than left-sided injuries, which is attributed to relative protection of the right hemi-diaphragm by the liver. The incidence of herniation of intra-abdominal contents is low, but when present can lead to severe morbidity from obstruction or strangulation of viscera. Because of the delay between diaphragmatic injury and diagnosis, patients often present with nonspecific symptoms, making identifying the correct diagnosis challenging. Definitive treatment involves surgical repair of the diaphragm, either through a thoracic or abdominal approach. We present the case of a patient found to have rightsided diaphragmatic rupture and hepatothorax two years after the inciting trauma.

Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries).

This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.

Traumatic Diaphragmatic Rupture

To describe changes in the presentation, examination of the chest in patients with diaphragmatic rupture, was reviewed to identify the difficulty in the diagnosis and treatment of this injury. Between April 2006-and December 2012, 38-patients with traumatic diaphragmatic rupture were treated, and analyzed demographic data , cause of injury, extent and location of the diaphragmatic lesion with herniated organs, were described the clinical presentation.Retrospective study of 38-cases, 36-male, 2-female, 37 cases left side, one case right side. Main cause was penetrating injury 35-cases, blast injury (12), gunshot (16), stab (7).Blunt injury 3-cases, road traffic accident (2), post-operative damage and tear the diaphragm (1) case. Average age33-year, range (4-65years old).The diagnosis made by C-XR, C-T Scan, MRI, were grade of injury II-IV most common, associated injury stomach, spleen, bowel, kidney, retroperitoneal hematoma, liver. Repair through laparotomy and thoracotomy. Chestpain abdominal pain shock was the main presentation. The study showed the suspicion beside the radiological C-XR, C-T Scan are very useful in initial diagnostic approach to traumatic diaphragmatic rupture. The difficulty is that diaphragmatic injuries particularly after penetrating trauma may initially go unnoticed and without changes in the C-XR Images diagnosis is made difficult. Early diagnosed, treatment reduces intra and postoperative morbidity and mortality.

FACILITIES OF HELICAL CT IN DIAGNOSTIC OF DIAPHRAGMATIC INJURIES AND ITS CONSEQUENCES

Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Acute traumatic rupture of diaphragm may be unrecognized and there is often a delay between the injury and the diagnosis. This article reviews the case reports of three patients. The first patient had a penetrating trauma of left diaphragm. The diagnosis was made 5 days later. The second patient had herniation with kidney, colon and intestine through the left diaphragmatic rupture. The third patient had right diaphragmatic rupture and herniation with hepar, сolon and stomach. Both cases were presented as early undiagnosed injuries.

English

Traumatic diaphragmatic ruptures are relatively rare, but are increasingly being reported due to their commonness in motor vehicle accidents. This case report is of a one-year old female child similarly injured, who presented very early after the insult, with none of the abdominal symptoms or signs that usually point to this diagnosis. This case underscores the fact that clinical scenario in pediatric patients does not always correlate with the degree of severity of injury and also that CT scan of chest is superior to radiographs and ultrasonography in detecting early diaphragmatic rupture.

Factors affecting mortality in traumatic diaphragmatic ruptures

Amac: Bu calismada diyafram rupturu nedeni ile cerrahi uygulanan hastalarda mortaliteyi ekileyen olasi faktorler arastirildi. Ca­lis­ma­pla­ni:­Mayis 1997 Mayis 2009 tarihleri arasinda toplam 30 hasta (27 erkek, 3 kadin; ort. yas 42.6 yil; dagilim 16-88 yil) diyafram rupturu nedeni ile klinigimizde ameliyat edildi. Hastalar mortaliteyi etkileyen olasi faktorler acisindan retrospektif olarak degerlendirildi. Yirmi iki hastaya acil cerrahi girisim ilk yedi gunde uygulandi. Diger alti hasta latent fazda ve iki hasta obstruktif fazda ameliyat edildi. Bul gu lar: Dokuz hastaya torakotomi, dokuz hastaya laparotomi ve 12 hastaya torakotomi ve laparotomi yapildi. Sekiz hastaya eksploratif laparotomi ile tani konuldu. Hastanede kalis suresi ortalama 12 gun (1-50 gun) idi. Sekiz hastada morbidite (%27) gorulur iken, yedi hastada (%23) mortalite goruldu. Bes hastada eslik eden yaralanma bulunamaz iken, 25 hastada eslik eden yaralanmalar vardi. Bu hastalarin 16’sinda (%53) eslik eden yaralanmalar icin ek cerrahi girisimler gerekti. Ileri yas (p=0.020) ve daha uzun sure yogun bakim ihtiyaci olmasi (p=0.020) mortaliteyi negatif yonde etkileyen faktorler olarak bulundu. So­nuc:­Eslik eden organ yaralanmalari morbidite ve mortaliteyi etkileyen ana prognostik faktordur. Ileri yas ve travmatik diyafram rupturune eslik eden organ yaralanmasi olan hastalarin mekanik ventilatorden erken ayrilmasi, agresif tedavi ve yakin takibi, morbidite ve mortaliteyi azaltabilir.