DIAPHRAGM INJURY

Diaphragm Injury

Diaphragm Injury

Introduction

Diaphragmatic injuries are relatively rare and result from either blunt trauma or penetrating trauma. Diagnosis and treatment are similar regardless of mechanism, although many management issues are specific to blunt trauma. Thus, this paper focuses on blunt injuries and details their specific differences from penetrating injuries.

Physical Findings

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(Baldassarre et al, 2007).

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 (Mintz et al, 2007).

Physical examination is limited in its utility in diagnosing this injury, but diaphragm 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 (Cui et al, 2007).

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 (Mintz et al, 2007).

The first, or acute, phase begins with the injury. 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(Baldassarre et al, 2007)

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 ...