History
Clinical presentation varies depending on the mechanism of injury (ie, blunt vs penetrating) and the presence of associated injuries. Symptoms of diaphragmatic injuries frequently are masked by associated injuries. The diaphragm is integral to normal ventilation, and injuries can result in significant ventilatory compromise. A history of respiratory difficulty and related pulmonary symptoms may indicate diaphragmatic disruption.
Diaphragmatic tears rarely occur in isolation. These patients often have associated thoracic and/or abdominal injuries or may have concomitant head or extremity trauma. The rates for associated injuries in blunt diaphragmatic rupture are as follows:
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Pelvic fractures in 40%
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Splenic rupture in 25%
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Liver laceration in 25%
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Thoracic aortic tear in 5-10%
Diaphragmatic rupture and thoracic aortic disruption are uniquely associated in blunt trauma. In a retrospective chart review, 1.8% of patients with blunt trauma had a diaphragmatic rupture, 1.1% had a thoracic aortic tear, and 10.1% had both. [13] In the last group, the mechanism was high-speed MVC. This association, although rare, is important to consider. The review authors suggested that when one diagnosis is evident, the clinician should further investigate the possibility of the other associated injury.
Physical
The physical examination should focus initially on airway, ventilation, and circulation, with concomitant management of airway, ventilatory, or circulatory compromise. Examination of the neck and chest should include a particular focus on findings of tracheal deviation (ie, mediastinal shift), symmetry of chest expansion, and absence of breath sounds (ie, lung displacement). Since the incidence of associated injuries is high, physical findings typically are dictated by these other injuries.
Early diagnosis
Diagnosis may not be obvious. It is made preoperatively in only 40-50% of left-sided and 0-10% of right-sided blunt diaphragmatic ruptures. In 10-50% of patients, diagnosis is not made in the first 24 hours.
Traumatic diaphragmatic injuries are just one of many injuries that can cause acute respiratory compromise. [14]
Physical examination is limited in its utility in diagnosing this injury, but diaphragmatic injury may be identified by auscultation of bowel sounds in the chest or dullness on percussion of the chest. A penetrating injury to the abdomen with a suggestion of a lung or thoracic injury indicates transgression of the diaphragm, as would a chest injury with any suggestion of abdominal injury.
Delayed diagnosis
If not made in the first 4 hours, the diagnosis may be delayed for months or years. Thus, 10-50% of blunt injuries (and an even greater percentage in penetrating trauma) are diagnosed late. This number is decreasing because of greater awareness and earlier identification.
Although the diagnosis may be missed regardless of mechanism, seemingly innocent penetrating injuries may be long forgotten by the patient and are the most commonly missed diaphragmatic injury.
The 3 clinical phases of diaphragmatic injuries were first described by Grimes [15] :
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The first, or acute, phase begins with the injury.
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If not diagnosed early, the second, or latent, phase occurs. This phase is asymptomatic but may evolve into gradual herniation of abdominal contents. The diagnosis may be made later because of complications of herniation of abdominal contents into the pleural cavity.
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The third, or obstructive phase, is characterized by bowel or visceral herniation, obstruction, incarceration, strangulation, and possible rupture of the stomach and colon. If herniation causes significant lung compression, it can lead to tension pneumothorax. Cardiac tamponade has been described from herniation of abdominal contents into the pericardium. Diaphragmatic paralysis also may occur.
Complications
Early deaths usually result from associated injuries rather than the diaphragmatic tear. Mortality ranges from 5 to 30%.
Serious morbidity usually is related to reexpansion pulmonary edema or to the laparotomy.
Paralysis or incoordination of the diaphragm is common, but more than 50% of these conditions resolve.
The late complications of an undiagnosed traumatic hernia include bowel herniation, incarceration, and strangulation; tension hemothorax secondary to massive bowel herniation; pericardial tamponade from herniation into the pericardial sac; and diaphragmatic paralysis that may recover after repair.
Death and significant morbidity rarely are related to delayed diagnosis. However, incarceration of herniated abdominal contents can lead to infarction or rupture with disastrous consequences.
