B. C. Patterson1, A. H. Palmer1, A. Ekeh1 1Wright State University,Department Of Surgery,Dayton, OH, USA
Introduction: Injuries to the diaphragm are rare events that typically require operative intervention, can occasionally be difficult to identify by current imaging techniques, have a higher occurrence with blunt mechanisms and are more predominant on the left side. We reviewed a single center’s experience with these injuries to determine if the patterns of presentation have evolved from reported historical trends.
Methods: All patients that sustained diaphragmatic injuries and presented to an American College of Surgeons verified Level I Trauma Center over an 8 year period (January 2004 – December 2011) were identified from the Trauma Registry. Demographic data, mechanism of injury, associated injuries, laterality, method of diagnosis, length of stay, mortality and other data points were abstracted from the patient records. Comparisons where necessary were performed by Student t-test and analysis of variance (ANOVA) for continuous variables and Fishers exact test for categorical ones.
Results:In the studied time period, there were 23,578 trauma admissions with 126 patients identified with diaphragmatic injuries. These represented 0.53% of all trauma admissions. The mean age was 37.0 years and 82% were male. Motor vehicle crashes (MVCs) – 40.5%, gunshot wounds – 36.5%, and stabbings – 11.1% were the most common etiologies of injury. Blunt mechanisms overall represented 50.8% with a mean Injury Severity Score (ISS) of 32.9. Penetrating mechanisms occurred in 49.2%. (mean ISS 21.5) Left-sided diaphragmatic injuries (65.9%) were more common than right sided (25.4%) and 7.9% were bilateral. Exploratory laparotomy was the most frequent method of diagnosis (45.2%). Chest X-ray (18.3%), CT (15.1%), Thoracotomy (6.3%) and Laparoscopy (4.8%) were the other diagnostic methods. Delayed diagnosis (>12 hours) occurred in 14.5% of patients with 10.3% of these found at autopsy. The overall mortality rate was 30.2%. Mortality was higher in blunt trauma – 40.6% vs. 19.4% in penetrating trauma. (p= 0.012) Patients who were stabbed had the lowest mortality rate (0%) while pedestrians trauma had the highest (80%). The laterality of the injury had no effect on mortality.
Conclusion: Diaphragmatic injuries are uncommon and can occasionally present a diagnostic challenge with delayed diagnosis –as seen in 14.5% of patients in this series. Left sided injuries predominate and mortality is higher with blunt trauma mechanisms – related to associated injuries. Exploratory laparotomy remains the most frequent method of diagnosis. Our findings are consistent with prior series in the literature with no major shifts in trends noted. Mechanisms due to penetrating injuries are higher in our study than has been historically reported.
No optimal imaging diagnostic technique has emerged for diaphragmatic injuries and a high index of suspicion remains necessary to avoid delayed diagnoses and missed injuries.