The diagnostic dilemma of diaphragm injury

Prompt diagnosis of acute traumatic injury to the diaphragm remains a challenge when the admission chest X-ray is unrevealing and immediate laparotomy or thoracotomy is not indicated. Diagnostic delay may contribute to significant morbidity and mortality. A retrospective review of our 15-year experience with diaphragm injury (DI) revealed 13 patients (nine male/four female; mean age, 40 +/- 34 years) who sustained injuries to the left (77%) and right (23%) diaphragm respectively as a result of motor vehicle crashes (MVCs) (69%), penetrating trauma (30%), and pedestrian-versus-car accidents (1%). Nine (69%) patients with timely diagnosis of DI underwent laparotomy for suggestive chest X-rays or other indications for immediate exploration. Four (31%) patients sustaining blunt trauma had DI missed on initial evaluation; all patients had initial radiographic evaluations of the chest and abdomen which ascribed abnormalities to intrathoracic pathology. In the one-day delay the diagnosis (right sided) was made at exploratory laparotomy for persistent abdominal pain. This 74-year-old patient, who also had sustained a duodenal injury, succumbed to sepsis. In the 17-day delay the patient had two chest CT scans and multiple bronchoscopies yet failed to wean from the ventilator before exploratory laparotomy which revealed the diagnosis. The third patient sustained multiple injuries after a MVC and underwent multiple imaging studies and back stabilization before discharge. Ten years later, after multiple negative gastrointestinal workups for abdominal pain a contrast study finally diagnosed herniated transverse colon in the left chest. This patient underwent successful repair via laparotomy. The fourth delayed diagnosis was made in a 72-year-old women who had been involved in an MVC 8 years earlier and had sustained multiple back fractures. She is scheduled for exploration in the near future. DI particulary after blunt trauma and on the right side may be missed in the absence of other indications for immediate surgery because radiographic abnormalities of the diaphragm particularly on the right are often attributed to thoracic pathology or may be absent initially. A high index of suspicion for DI may help lead to an earlier diagnosis especially when the patient's clinical condition fails to improve.