Traumatic diaphragmatic hernia. Occult marker of serious injury.

OBJECTIVE

Recent experience with traumatic diaphragmatic hernias at the Massachusetts General Hospital was reviewed to identify pitfalls in the diagnosis and treatment of this injury.

SUMMARY BACKGROUND DATA

Traumatic diaphragmatic disruption is a common injury and a marker of severe trauma. It occurs in 5% of hospitalized automobile accident victims and 10% of victims of penetrating chest trauma. Numerous reports describe splenic rupture in 25% of patients with blunt diaphragmatic rupture, liver lacerations in 25%, pelvic fracture in 40%, and thoracic aortic tears in 5%. Diaphragmatic rupture is a predictor of serious associated injuries which, unfortunately, is itself often occult.

METHODS

A chart review of all patients admitted to the Trauma Service with traumatic diaphragmatic hernias was undertaken for the period of January 1982 to June 1992.

RESULTS

Data on 68 patients sustaining blunt (n = 25) and penetrating (n = 43) diaphragmatic rupture or laceration were presented. The diagnosis was made preoperatively in only 21 (31%). Associated injuries were frequent in those injured by either blunt or penetrating trauma. Sixty-six patients underwent repair, 54 (82%) through a laparotomy alone and 12 (18%) with the addition of a thoracotomy. There were five (7.4%) deaths that were caused by coagulopathy, hemorrhagic shock, multisystem organ failure, and pulmonary embolism. Complications were twice as frequent in the blunt-trauma group and included abscess, pneumonia, and the sequelae of closed head injuries.

CONCLUSIONS

The recognition of diaphragmatic rupture is important because of the frequency and severity of associated injuries. The difficulties in reaching the diagnosis require an aggressive search in patients at risk.