Blunt diaphragmatic rupture

To identify (1) predictors of outcome in blunt diaphragmatic rupture (BDR), and (2) factors contributing to diagnostic delay.

We reviewed the charts and radiographs of 41 patients with BDR treated in our Hospital from 1988 to 1997. There were 35 male (85%) and six female, aged 17-71 (mean: 41) years. BDR was left-sided in 24 cases (58%), right-sided in 15 (36%) and bilateral in two (5%).

Two groups of patients can be identified: group A (n = 36, 88%) with acute BDR, and group B (n = 5, 12%) with post-traumatic diaphragmatic hernia (TDH). In group A, immediate diagnosis was made in 35 cases (97%), but only in 26 (72%) preoperatively. In one case, a right BDR was missed on initial evaluation but became apparent 2 weeks later. Associated injuries were present in 34 patients (94%) involving: spleen (n = 18), rib fractures (n = 17), liver (n = 14), lung (n = 11), bowel (n = 7), kidney (n = 5) and other fractures (n = 21). Injury Severity Score (ISS) ranged from 9 to 66 (mean: 31). BDR repair was accomplished through a laparotomy in 22 cases, thoracotomy in 10 and laparo-thoracotomy in four. The overall mortality rate was 16.6% (6/36). Both patients with bilateral BDR died. The patients who died were older than the survivors (mean age: 54 vs. 39 years, P<0.05), were more severely injured (mean ISS: 46 vs. 28, P<0.05) and were in shock (100 vs. 23%, P<0.05). In group B with TDH, diagnosis was delayed for 7-16 months after injury. Four patients had non-specific clinical signs and one strangulation of hollow viscera. One patient had undergone surgery during acute injury but BDR was overlooked. Location of TDH was on the left in three cases and on the right in two. Delay in BDR diagnosis was 12.5% (3/24) in patients with left-sided and 20% (3/15) in patients with right-sided lesions (P>0.1). Repair of TDH was achieved through thoracotomy in all cases. No mortality or major morbidity were encountered.

(1) Predictors of BDR mortality are: age, ISS and hemodynamic status of the patient. (2) Delay in diagnosis does not influence the outcome and is not influenced by the side of BDR location. (3) BDR can easily be missed in the absence of other indications for prompt surgery, where a thorough examination of both hemidiaphragms is mandatory. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis.