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Diaphragmatic injuries: challenges in the diagnosis and management

Division of Trauma & Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, LAC+USC Medical Center, Los Angeles, CA, USA, petrone{at}usc.edu

Ari Leppäniemi

Department of Surgery, Meilahti Hospital, University of Helsinki, Helsinki, Finland

Kenji Inaba

Division of Trauma & Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, LAC+USC Medical Center, Los Angeles, CA, USA

Kjetil Søreide

Department of Surgery, Stavanger University Hospital and Acute Care Medicine Research Network, University of Stavanger, Stavanger, Norway

Juan A Asensio

Division of Trauma & Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, FL, USA

Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging for the trauma surgeon, as it is often clinically occult. Accurate diagnosis is critical however as a missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. The etiology of DI includes the following mechanisms: blunt, penetrating, and iatrogenic. Vital information about the mechanism of injury should be obtained from the emergency medical personnel. Left-sided hemidiaphragmatic injuries are considerably more common than right-sided injuries. Patients with right-sided hemidiaphragm rupture have higher pre-hospital mortality resulting from the greater impacting force require to produce a right-sided DI, associated with significant vascular injury. The diagnosis of a DI by imaging studies presents a challenge, as evidenced by the large number of investigative procedures employed to establish the diagnosis. Minimally invasive technology in the form of laparoscopy and thoracoscopy is in the trauma surgeon's diagnostic and therapeutic armamentarium. The surgical care of DI can be classified according to the phase of clinical presentation, into injuries requiring management in their acute phase versus those in their chronic phase. The patient's survival depends on the severity of their associated injuries, but if DI is not diagnosed promptly a missed injury can be associated with a high morbidity and mortality.

Key Words: diaphragm • injury • imaging studies • diagnosis • surgery • morbidity • mortality

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