Diaphragmatic injuries.

This study seeks to define the clinical presentation, the usefulness of diagnostic tests, surgical management approach and outcome of treatment among patients with diaphragmatic injuries. One hundred and sixteen patients with diaphragmatic injuries were treated. This was 6.5% of 1,778 chest trauma patients. Eighty-four of these patients (6.8%) were among 1230 patients who had blunt chest injury and the remaining 32 patients (5.8%) were among 548 patients who had penetrating chest injury. The commonest mechanisms of injury were motor vehicle accidents (48.8%) for blunt and gunshot wounds (56.3%) for penetrating diaphragmatic injuries. The left diaphragm was most commonly involved (86.9% for blunt, 59.4% for penetration), 12.5% of the patients with penetrating chest injury had bilateral diaphragmatic injuries. There were no bilateral diaphragmatic injuries amongst the patients with blunt chest injury. Chest radiographs gave a highly positive yield in the diagnosis of blunt diaphragmatic hernias (67.9%) while nonspecific chest radiological findings (59.4%) were more common among those with penetrating injuries. In 57 patients (49.1%) out of 116, preoperative diagnosis of diaphragmatic hernia was certain. In the remaining 59 patients (50.9%), diagnosis was intraoperative (40 patients), or at postmortem (19 patients). Surgery was emergent in 69 patients (71.1%), semi emergent in 21 patients (21.6%) and elective in 7 patients (7.2%). Surgical approaches were mainly thoracotomy (57 patients), laparotomy (17 patients), laparotomy and thoracotomy (20 patients). In seventy seven patients (79.4%) the diaphragmatic injuries were left sided and in 20 patients (20.6%), the diaphragmatic injuries were right sided. There were 19 preoperative and 21 postoperative deaths. The overall mortality was 34.5%. Associated abdominal and thoracic injuries were the commonest causes of mortality among the patients with diaphragmatic injuries in this study. We conclude that diaphragmatic injury should be suspected in all thoracoabdominal trauma. Lack of specific signs and symptoms is common and a high index of suspicion is required. Routine chest radiograph remains the best screening test for diaphragmatic rupture. Diaphragmatic injury may be a predictor of severity of injury in blunt trauma patient. Surgical approach should be individualized.