Diaphragmatic injuries: Therapy and diagnosis

Abstract

Traumatic diaphragmatic injury (DI) is a unique clinical entity that is usually occult and can easily be missed. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of DI challenging to the trauma surgeons. Diaphragmatic injury may result within closed, blunt thoracoabdominal trauma or acute, penetrating thoracic, abdominal and thoracoabdominal trauma. Signs and symptoms of diaphragm injury are not specific and often remain undetected due to serious associated injuries, which distract surgeons' attention, complicating the diagnosis. Since it is not that frequent, little attention has been paid. For all above-mentioned, preoperative diagnosis is established with less than 1/2 of patients, with 44% on autopsy or intraoperatively accidentally, and in about 14% it was delayed even for several years. Many authors have tried, and Grimes has succeeded in introducing three phases of diaphragmatic injury describing acceptable system of detecting this organ injury: Acute phase - the diaphragmatic rupture, usually missed, because symptoms of associated injuries of organs prevail; Latent phase - with viscera partially protruding through diaphragmatic opening. It is characterised by mild symptoms of discomfort and uneasiness in hypohondrium and hemithorax of the injured side. Signs of dyspnoea and orthopnoea are moderate, and there might be a radiograph after chest X-ray; Obstructive phase - where the abdominal organs penetrate into the thorax and symptoms resulting from an obstruction or ischemia occur. It is usually characterised by Borchardt's Triad (strong epigastric pain, vomiting and the inability to pass a nasogastric tube), with X-ray indicating mediastinum shift, with obvious penetration of abdominal organs into the pleural space. Any diaphragmatic injury requires operational treatment, since this organ's injuries cannot spontaneously heal. Even injuries of smaller dimensions must be sutured to prevent outcome such as diaphragmatic hernia and its consequences.