Current trends in the diagnosis and management of traumatic diaphragmatic injuries: A systematic review and a diagnostic accuracy meta-analysis of blunt trauma

BACKGROUND

Traumatic diaphragmatic injuries (TDI) are wounds or ruptures of the diaphragm due to thoraco-abdominal trauma. Nowadays, CT-scan is considered the gold standard for TDI diagnosis. The aim of this study was to assess the current diagnostic accuracy of CT-scan in the diagnosis of TDI and describe the management of this type of injury.

METHODS

A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent reviewers searched the literature in a systematic fashion using online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the diagnosis and the following management of TDI were included. Pooled estimates of sensitivity, specificity, and positive/negative likelihood (with corresponding 95% confidence intervals) were analyzed based on the bivariate model for blunt TDI. The Newcastle-Ottawa scale for cohort studies was used for the quality assessment of selected articles. The PROSPERO registration number was as follows: CRD42022301282.

RESULTS

Fifteen studies published between 2001 and 2019 were included. All included studies reported a contrast-enhanced computed tomography as the preferred method to obtain diagnostic imaging. Left-sided TDI was the type of injury most frequently found. False negative TDI at CT-scan were more frequent than false positive TDI (11.13 ± 23.24 vs. 2.66 ± 6.65). Six studies on blunt TDI were included in the meta-analysis, showing a high sensitivity [0.80 (95%CI 0.65-0.90)] and specificity [0.98 (95%CI 0.89-1.00)] of the CT-scan in detecting TDI. Overall, 7 articles reported laparotomy as the method of choice to repair TDI. Only 3 studies reported a laparoscopic and/or thoracoscopic approach to TDI repair.

CONCLUSION

CT-scan has a good sensitivity and specificity for blunt TDI diagnosis. However, TDI diagnosis and management are often delayed. The use of water-soluble contrast in CT-scan should be considered when the diagnosis of TDI is not defined after the first scan, and clinical suspicion is still high. In this context, a highly trained trauma team is essential for trauma management and correct imaging interpretation.

Laparotomy management of diaphragmatic and hollow viscera rupture combined with thoracic endovascular aortic repair after a traffic accident: A case report

Introduction

Road traffic incidents are the most common cause of multiple organ trauma in low- and middle-income countries. Multiple blunt intra-abdominal organs that rupture in conjunction with a ruptured aorta are terrible and rare.

Case presentation

A 65-year-old man sustained critical injuries during a traffic collision between a motorcycle and truck. The Injury Severity Score was 42 points,. After open abdominal exploration, we repaired the left diaphragmatic rupture with a 13-cm-long tear of IV grade (American Association for the Surgery of Trauma), resected partial small bowel, simple suture of the transverse colon, and Hartmann procedure in the descending colon. Thoracic endovascular aortic repair (TEVAR) was performed 22 h after laparotomy. Reconstruction of the head depicting a cheekbone fracture and inferior to the left orbital bone was performed on the 14th day. The patients survived and were discharged from the hospital, at 22 days without morbidity or mortality.

Discussion

Diaphragmatic rupture provides a signal to relate head, thoracic, and abdominal blunt trauma. If the patient sustains more serious life-threatening injuries that require emergency laparotomy or craniotomy, and aortic repair may be delayed. Laparotomy is the best initial surgical method in this case. TEVAR is a feasible and gold standard procedure for the treatment of patients with the necessary indications.

Conclusion

It is essential to evaluate the level of organ damage to properly coordinate the specialists. The timing of the operation and therapeutic alternatives should be decided for each patient.

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Traumatic diaphragmatic rupture (TDR) provides a signal to relate head, thoracic, and abdominal injuries.

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Multiple blunt intra-abdominal organs ruptured in conjunction with a ruptured aorta are terrible and rare traumas.

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Laparotomy is the best initial method and TEVAR is feasible for hemodynamically stable patients.

Successful thoracoscopic repair of traumatic diaphragmatic hernia in a child

Traumatic diaphragmatic hernia is very rare in children, and the diagnosis is often missed or delayed. Herein, we reported a 2-year-old boy who had suffered with traumatic diaphragmatic hernia due to a car crash. The child was manifested as tachypnoea without any other severe symptoms. The computed tomography scanning showed his right diaphragm was rupture. Soon, this patient was received a thoracoscopic repair surgery, and he was discharged 2 weeks later without any complication.

Role of thoracoscopy in traumatic diaphragmatic hernia

Thoraco-abdominal trauma can in rare cases involve diaphragmatic rupture and subsequent herniation of intra-abdominal contents. We report a case of this complication in a 5-year-old boy who was injured in a car crash, and who manifested respiratory distress and hemodynamic instability after 48 h of being monitored in the pediatric intensive care unit. Multiple radiologic investigations were inconclusive and the definite diagnosis was established only on thoracoscopic exploration.

Laceration of the Diaphragm: An Autopsy Series

In the surgical literature, laceration of the diaphragm is reported three times more often on the left side than the right, and bilateral lacerations are uncommon. However, in reported autopsy series, right, left, and bilateral lacerations occur at approximately equal frequencies. Few reports mention lacerations of the diaphragmatic crura. This retrospective case series describes the spectrum of autopsy findings in subjects with diaphragmatic lacerations and includes lacerations of the crura.

Methods

Records were reviewed from a consecutive series of 145 autopsies on subjects who died in traffic accidents or falls or leaps from a great height. The diagnostic standard was direct observation at autopsy.

Results

Twenty-two subjects had laceration of the diaphragm. Of these, four had a right leaf laceration, five had left leaf laceration, five had bilateral leaf lacerations, and nine had crural lacerations. Eight subjects with leaf lacerations also had herniations of viscera through the laceration. The lacerations ranged in length from 4 to 20 cm. All subjects sustained additional trauma to the torso. Nineteen of 22 subjects died of severe central nervous system trauma, cardiac or aortic trauma, or both.

Conclusions

Lacerations of the diaphragmatic crura are more common than previously reported. The incidence of right, left, and bilateral leaf lacerations is similar to that reported in other autopsy series. Lacerations of the diaphragm are associated with severe trauma of the central nervous system, heart, and aorta.

Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience

BACKGROUND

Traumatic diaphragmatic injury (TDI) is usually associated with multiple injuries. We aimed to evaluate the patterns, associated injuries, and predictors of in-hospital mortality of patients with TDI.

METHODS

The trauma registry from a Primary Adult Resource Center for Trauma was queried for patients admitted with a TDI from January 1995 to December 2009. Patient characteristics, mechanism of injury, associated injuries, management, and outcomes were analyzed. We compared morbidity and mortality in left and right diaphragmatic injuries (LDI and RDI, respectively).

RESULTS

Of the 773 patients, 650 were male (84%), with a mean (SD) age of 33 (15). Mechanism of injury was penetrating in 561 (73%) and blunt in 212 (27%) patients. LDI, RDI, and bilateral injuries were 57%, 40%, and 3%, respectively. The majority of cases were managed by exploratory laparotomy and direct suture repair. LDI was associated with higher rates of splenic, gastric, and pancreatic injuries and prolonged hospital stay in comparison with RDI. In comparison with LDI, RDI was associated with higher rates of deaths (26% vs. 17%, p = 0.003). Overall, mortality in TDI was 21%. Age (odds ratio [OR], 1.02, p = 0.008), Injury Severity Score (ISS) (OR, 1.09, p = 0.001), associated cardiac injury (OR, 2.8, p = 0.005), left diaphragmatic injury (OR, 0.53, p = 0.005), and operative interventions (OR, 0.32, p = 0.001) were independent predictors for mortality.

CONCLUSION

This largest single institution study on TDI in the literature confirms that LDI are more commonly diagnosed than RDI. Exploratory laparotomy is the most common procedure performed for these injuries. Young age and operative interventions are associated with favorable outcome, whereas high ISS, RDI, and associated cardiac injury are independent predictors for mortality.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTION

Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

PRESENTATION OF CASE

A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

DISCUSSION

We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

CONCLUSION

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Chest trauma in children, single center experience

Trauma is the leading cause of mortality in children over one year of age in industrialized countries. In this retrospective study we reviewed all chest trauma in pediatric patients admitted to Mansoura University Emergency Hospital from January 1997 to January 2007. Our hospital received 472 patients under the age of 18. Male patients were 374 with a mean age of 9.2±4.9 years. Causes were penetrating trauma (2.1%) and blunt trauma (97.9%). The trauma was pedestrian injuries (38.3%), motor vehicle (28.1%), motorcycle crash (19.9%), falling from height (6.7%), animal trauma (2.9%), and sports injury (1.2%). Type of injury was pulmonary contusions (27.1%) and lacerations (6.9%), rib fractures (23.9%), flail chest (2.5%), hemothorax (18%), hemopneumothorax (11.8%), pneumothorax (23.7%), surgical emphysema (6.1%), tracheobronchial injury (5.3%), and diaphragm injury (2.1%). Associated lesions were head injuries (38.9%), bone fractures (33.5%), and abdominal injuries (16.7%). Management was conservative (29.9%), tube thoracostomy (58.1%), and thoracotomy (12.1%). Mortality rate was 7.2% and multiple trauma was the main cause of death (82.3%) (P<.001). We concluded that blunt trauma is the most common cause of pediatric chest trauma and often due to pedestrian injuries. Rib fractures and pulmonary contusions are the most frequent injuries. Delay in diagnosis and multiple trauma are associated with high incidence of mortality.

Traumatic diaphragmatic ruptures: clinical presentation, diagnosis and surgical approach in adults

Objective: Traumatic diaphragmatic injuries are rare, but potentially life-threatening due to herniation of abdominal organs into the pleural cavities. They can be easily overlooked on initial diagnostics and a high index of suspicion is required. The aim of this retrospective study was to analyze the clinical presentation, diagnostic methods and surgical management of patients with diaphragmatic rupture at our institution.

Methods: A retrospective study was performed to analyze our experience with patients suffering from traumatic diaphragmatic rupture. Charts were reviewed for sex, age, side-location, concomitant injuries, time-to-diagnosis, diagnostic methods, surgical approach and outcome.

Results: Fourteen patients (median age: 46 yrs, range 18–71, 9 male, 5 female) with diaphragmatic injuries (left side: 10, right side: 4) were treated between July 2003 and September 2011. Mechanism of injury was a penetrating trauma (14%), blunt trauma (50%) and others (36%). Associated abdominal injuries included spleen rupture (n=3), liver laceration (n=2), abdominal wall laceration (n=2) and gastric perforation (n=1). Computed tomography was the most sensitive diagnostic method. All patients underwent trans-abdominal repair of the diaphragmatic defect (direct suture: 10, prosthetic mesh insertion: 4). Associated abdominal procedures included splenectomy (n=3), liver packing (n=2), abdominal wall reconstruction (n=2) and partial gastric resection (n=1). Morbidity and hospital mortality rate were 36% and 0%, respectively. Median postoperative hospital stay was 17 days (range: 7–40 days).

Conclusion: Morbidity and mortality of diaphragmatic ruptures are mainly determined by associated injuries or complications of diaphragmatic herniation like incarceration of viscera or lung failure. Early diagnosis helps to prevent severe complications. Spiral CT-scan is the most reliable tool for acute diagnosis of diaphragmatic rupture and associated visceral lacerations. Laparotomy is an adequate surgical approach for diaphragmatic repair, especially in cases of associated abdominal organ injury.

Road traffic injuries and data systems in Egypt: addressing the challenges

OBJECTIVE

Road traffic injuries (RTIs) are a major cause of global mortality and morbidity, killing approximately 1.3 million people and injuring 20 to 50 million each year. The significance of this public health threat is most pronounced in low- and middle-income countries where 90 percent of the world's road traffic-related fatalities take place. Current estimates for Egypt show a road traffic fatality rate of 42 deaths per 100,000 population-one of the highest in the Eastern Mediterranean Region. RTIs are also responsible for 1.8 percent of all deaths and 2.4 percent of all disability-adjusted life years (DALYs) lost in the country. Despite this, studies surrounding this topic are scarce, and reliable data are limited. The overall goal of this article is to define the health impact of RTIs in Egypt and to identify the strengths and weaknesses of each data source for the purpose of improving the current RTI data systems.

METHODS

A 2-pronged approach was undertaken to assess the burden of RTIs in Egypt. First, a thorough literature review was performed using PubMed, Embase, ISIS Web of Knowledge, and Scopus databases. Articles pertaining to Egypt and road traffic injuries were selected for screening. With assistance from Egyptian colleagues, a comprehensive exploration of data sources pertaining to RTIs in Egypt was undertaken and secondary data from these sources were procured for analysis.

RESULTS

The literature review yielded a total of 20 studies, of which 6 were multi-country and 5 were hospital-based studies. None examined risk factors such as speeding, alcohol, or seat belt use. Secondary data sources were acquired from national hospital-based injury surveillance; a community-based health survey; pre-hospital injury surveillance; the Ministry of Transport; the General Authority for Roads, Bridges and Land Transport; death certificates; and the central agency for public motorization and statistics. Risk factor data are also limited from these sources.

CONCLUSION

The results of this article clearly highlight the significant burden that road traffic injuries pose on the health of the Egyptian population. The hospital-based injury surveillance system that has been established in the country and the use of International Classification of Diseases (ICD-10) coding brings the system very closely in line with international guidelines. There is, however, some considerable room for improvement, including the need to extend the coverage of the surveillance system, the inclusion of injury severity scores and disability indicators, and standardization of the sometimes rather disparate sources from various sectors in order to maximally capture the true burden of RTIs.

Management of patients with traumatic rupture of the diaphragm

Background

Traumatic rupture of the diaphragm is an unusual type of trauma. In addition, it is difficult to diagnose because it can be accompanied by injuries to other organs. If it is not detected early, the mortality rate can increase due to serious complications. Diaphragmatic rupture is an important indicator of the severity of the trauma. The aim of this study was to investigate the factors affecting the incidence of complications and mortality in patients who had surgery to treat traumatic rupture of the diaphragm.

Materials and Methods

The subjects were patients who had undergone a diaphragmatic rupture by blunt trauma or stab wounds except patients who were transferred to other hospitals within 3 days of hospitalization, from January 2000 to December 2007. This study was a retrospective study. 43 patients were hospitalized, and 40 patients were included during the study period. Among them, 28 were male, 12 were female, and the average age was 42 (from 18 to 80). Outcome predictive factors including hypoxia, ventilator application days, revised trauma score (RTS), injury severity score (ISS), age, herniated organs, complications, and the mortality rate were investigated.

Results

Causes of trauma included motor vehicle crashes for 20 patients (50%), falls for 10 (25%), stab wounds for 8 (20%), and agricultural machinery accidents for 2 (5%). Most of the patients (36 patients; 90%) had wound sites on the left. Diagnosis was performed within 12 hours for most patients. The diaphragmatic rupture was diagnosed preoperatively in 27 patients (70%) and in 12 patients (30%) during other surgeries. For surgical treatment, thoracotomy was performed in 14 patients (35%), laparotomy in 11 (27.5%), and a surgery combining thoracotomy and laparotomy in 15 patients (37.5%). Herniated organs in the thoracic cavity included the stomach for 23 patients (57.5%), the omentum for 15 patients (37.5%), the colon for 10 patients (25%), and the spleen for 6 patients (15%). Accompanying surgeries included splenectomy for 13 patients (32.5%), lung suture for 6 patients (15%), and liver suture for 5 patients (12.5%). The average hospital stay was 47.80±56.72 days, and the period of ventilation was 3.90±5.8 days. The average ISS was 35.90±16.81 (11~75), and the average RTS was 6.46±1.88 (1.02~7.84). The mortality rate was 17.5% (7 patients). Factors affecting complications were stomach hernia and age. Factors affecting the mortality rate were ISS and RTS.

Conclusion

There are no typical symptoms of the traumatic rupture of the diaphragm by blunt trauma. Nor are there any special methods of diagnosis; in fact, it is difficult to diagnose because it accompanies injuries to other organs. Stab wounds are also not easy to diagnose, though they are relatively easy to diagnose compared to blunt trauma because the accompanying injuries are more limited. Suture of the diaphragm can be performed through the chest, the abdomen, or the thoracoabdomen. These surgical methods are chosen based on accompanying organ injuries. When there are many organ injuries, there are a great number of complications. Significant factors affecting the complication rate were stomach hernia and age. ISS and RTS were significant as factors affecting the mortality rate. In the case of severe trauma such as pelvic fractures, frequent physical examinations and chest X-rays are necessary to confirm traumatic rupture of the diaphragm because it does not have specific symptoms, and there are no clear diagnosis methods. Complications and the mortality rate should be reduced with early diagnosis and with treatment by confirming diaphragmatic rupture in the thoracic cavity and the abdomen during surgery.

Laparoscopic treatment of a rare right diaphragmatic rupture with small bowel herniation after blunt thoracic trauma

Blunt traumatic diaphragmatic rupture (BTDR) is a life-threatening condition with an incidence from 0,8%-1,6% in blunt trauma, mostly located on the left side. The main prognostic factors are severe side injuries and the delay of diagnosis. We present a rare case of a 68-year-old female, with an isolated right diaphragm rupture. The diagnosis was done with a delay of 4 days by thoracic radiographs, which showed a herniation of small bowel into the right thoracic cavity. A reposition of the small bowel and a closure of the diaphragmatic defect by running suture were carried out laparoscopicly. Although large prospective studies concerning the outcome of laparoscopic approach to right BTDR are still missing, we could show, that laparoscopy can be performed safely in right traumatic diaphragm rupture.

Traumatic diaphragmatic hernia: tertiary centre experience

BACKGROUND

Traumatic diaphragmatic hernia (TDH) resulting from traumatic diaphragmatic rupture (TDR) may not be easily detected and can lead to significant morbidity and mortality.

PATIENTS AND METHODS

A retrospective case note analysis was performed of all patients treated for TDR at a major teaching hospital between March 2003 and March 2008. The aetiological factors, associated injuries, management and outcome were analysed.

RESULTS

Twenty-seven patients were studied (24 males, 3 females) and their ages ranged from 16 to 72 years (median 35 years). TDR was left-sided in 85% and right-sided in 15%. Aetiology was blunt trauma in 81% and 19% had penetrating injury. Associated injuries were present in 81%. The most common approach for repair was transabdominal (89%); additional thoracotomy was needed in 11%. Herniation of abdominal contents was present in 85% and herniation of more than one organ was present in 57%. The diaphragmatic rent was repaired primarily in 89% using nonabsorbable sutures. Post-operative pulmonary complications occurred in 52% of patients. Three patients (11%) died.

CONCLUSION

Left-sided blunt traumatic diaphragmatic rupture was more common than right-sided rupture. The most commonly herniated organs were the stomach and colon. Most ruptures could be repaired by an abdominal approach, which also allowed a complete exploration of the abdominal organs. Careful attention should be given to associated intra-abdominal injuries. Most of the defects were repaired directly using nonabsorbable sutures.