Overview
Definition:
A diaphragmatic injury involves a tear or defect in the diaphragm, the musculotendinous sheet separating the thoracic and abdominal cavities
Thoracoabdominal injuries often involve both cavities, making diaphragmatic injury repair a critical component of managing such complex trauma.
Epidemiology:
Diaphragmatic injuries occur in 1-7% of all blunt and penetrating thoracoabdominal trauma cases
Blunt trauma accounts for a higher proportion of ruptures, often associated with high-energy mechanisms like motor vehicle accidents
Penetrating injuries are more common in urban settings.
Clinical Significance:
Diaphragmatic injuries can lead to severe morbidity and mortality due to herniation of abdominal contents into the thorax, respiratory compromise, hemodynamic instability, and increased risk of infection
Prompt diagnosis and repair are vital for patient survival and recovery.
Clinical Presentation
Symptoms:
Shortness of breath
Chest pain
Abdominal pain
Shoulder tip pain (Kehr's sign) due to diaphragmatic irritation
Nausea or vomiting
Hypoxia
Tachycardia
Hypotension.
Signs:
Diminished breath sounds on the affected side
Bowel sounds heard in the chest
Paradoxical chest wall movement
Abdominal distension
Signs of hemorrhagic shock.
Diagnostic Criteria:
No specific diagnostic criteria exist
diagnosis relies on high index of suspicion in thoracoabdominal trauma combined with imaging and intraoperative findings
Clinical signs are suggestive, but definitive diagnosis often requires imaging or surgical exploration.
Diagnostic Approach
History Taking:
Mechanism of injury (blunt vs
penetrating)
High-energy impact
Associated injuries
Hemodynamic status
Previous abdominal or thoracic surgery.
Physical Examination:
Complete trauma survey (ATLS protocol)
Assess respiratory effort and adequacy
Auscultate chest for bowel sounds and decreased breath sounds
Palpate abdomen for tenderness, rigidity, or distension.
Investigations:
Chest X-ray: May show elevated hemidiaphragm, abnormal contour, or herniated contents
CT scan: Gold standard for diagnosing diaphragmatic injuries, delineating the extent of rupture and associated injuries
Sensitivity >95%
Ultrasound (FAST scan): Can detect free fluid but is less sensitive for diaphragmatic injury itself
Laboratory tests: Complete blood count, electrolytes, coagulation profile, arterial blood gases.
Differential Diagnosis:
Hemothorax
Pneumothorax
Pulmonary contusion
Solid organ injury (spleen, liver)
Hollow viscus injury
Rib fractures.
Management
Initial Management:
Airway, Breathing, Circulation (ABC) stabilization as per ATLS
Resuscitation with intravenous fluids and blood products
Chest tube insertion if indicated for hemothorax or pneumothorax
Analgesia
Consider intubation and mechanical ventilation for respiratory compromise.
Surgical Management:
Surgical intervention is indicated for symptomatic diaphragmatic injuries, large defects, or when associated with other abdominal injuries requiring laparotomy
Indications include hemodynamic instability, respiratory compromise due to herniation, or significant herniation of abdominal contents
Options include primary repair, prosthetic mesh repair for large defects, and repair via laparotomy, thoracotomy, or thoracoabdominal incision
Laparoscopic repair is increasingly used for stable patients with smaller, peripheral injuries.
Surgical Indications:
All penetrating diaphragmatic injuries
Significant blunt diaphragmatic injuries with herniation
Hemodynamic instability secondary to diaphragmatic injury
Associated intra-abdominal injuries requiring laparotomy
Respiratory compromise due to diaphragmatic injury.
Surgical Techniques:
Laparotomy: Preferred approach for most thoracoabdominal trauma with diaphragmatic injury, allowing simultaneous repair of abdominal injuries
Thoracotomy: Used for posterior or extensive injuries
Thoracoabdominal incision: Provides access to the entire diaphragm but is more extensive
Laparoscopic repair: Minimally invasive option for stable patients
Repair involves direct suture approximation of torn edges, often with absorbable or non-absorbable sutures
Large defects may require prosthetic mesh (e.g., Gore-Tex, Marlex) for reconstruction.
Complications
Early Complications:
Postoperative pneumonia
Atelectasis
Wound infection
Hemorrhage
Diaphragmatic dehiscence
Organ damage during repair.
Late Complications:
Chronic pain
Incisional hernia
Bowel obstruction due to adhesions
Persistent diaphragmatic dysfunction
Recurrent herniation.
Prevention Strategies:
Meticulous surgical technique
Secure closure of the diaphragm
Adequate pain control to facilitate deep breathing
Early mobilization
Prophylactic antibiotics if indicated
Close monitoring for signs of complications.
Prognosis
Factors Affecting Prognosis:
Mechanism of injury (penetrating injuries generally have better prognosis than blunt)
Presence and severity of associated injuries
Timeliness of diagnosis and repair
Patient's overall health status and hemodynamic stability
Skill of the surgical team.
Outcomes:
With prompt diagnosis and appropriate surgical repair, the prognosis for isolated diaphragmatic injuries is generally good
However, mortality and morbidity increase significantly with delayed diagnosis, extensive associated injuries, and hemodynamic compromise.
Follow Up:
Postoperative follow-up typically includes clinical assessment, chest X-ray to assess for recurrence or complications, and evaluation for incisional hernia
Long-term follow-up may be necessary for patients with large defect repairs or significant associated injuries.
Key Points
Exam Focus:
High index of suspicion for diaphragmatic injury in thoracoabdominal trauma
CT scan is the investigation of choice
Laparotomy is often the preferred surgical approach for combined thoracoabdominal injuries
Primary repair is feasible for most acute tears
mesh is reserved for large defects or chronic injuries
Complications like herniation and respiratory compromise are critical concerns.
Clinical Pearls:
Remember Kehr's sign (left shoulder pain) can indicate diaphragmatic irritation
Bowel sounds in the chest are a classic, though not always present, sign
Do not assume a normal chest X-ray rules out diaphragmatic injury, especially in blunt trauma.
Common Mistakes:
Delayed diagnosis due to subtle presentation
Inadequate imaging to assess the full extent of injury
Inappropriate surgical approach for associated injuries
Inadequate repair leading to dehiscence or herniation.