Blunt trauma of the diaphragm: a 15-county, private hospital experience

During a 6-year period, 52 patients with nonpenetrating trauma to the diaphragm were treated in eight acute care hospitals, serving a 15-county area of Michigan. Charts were reviewed to identify patterns of injury, treatment, and outcome. Preoperative diagnosis was made in 50 per cent of cases based on chest x-ray findings; the remainder were diagnosed intraoperatively. Clinical examination revealed respiratory distress, decreased breath sounds, or elevated hemidiaphragm in 81 per cent of patients. Forty-two per cent of patients sustained significant head injuries. Fractures were present in 75 per cent of patients. Major chest injury was found in 92 per cent. Intra-abdominal organs were herniated in 67 per cent of cases with the stomach being most common (54%). The spleen was the most commonly injured abdominal organ (60%). The left diaphragm was injured in 75 per cent of cases; 2 per cent were bilateral. The most common postoperative complication was pneumonia. Mortality in this series was 13 per cent, with no case being related to the diaphragmatic injury. The authors conclude that blunt injuries to the diaphragm in the multiply-injured patient present a clinical diagnostic challenge requiring a high index of suspicion. Optimal care requires a multi-disciplinary critical care team to manage the high incidence of associated central nervous system, orthopedic, and chest injuries and associated high mortality rates.