TRAUMATIC RUPTURE OF DIAPHRAGM

Traumatic diaphragmatic rupture remains a diagnostic challenge, and as sociated injuries determine the outcome in those diagnosed early, wher eas that of latent cases is dependent on the consequence of the diaphr agmatic rupture: namely, the diaphragmatic hernia. To analyze the clin ical and radiologic features and the therapeutic implications, we revi ewed 980 patients reported in the English-language literature. This in jury affects predominantly males (male:female = 4:1) in the third deca de of life, and is often caused by blunt trauma (75%). There were 1,00 0 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-si ded, 15 (1.5%) bilateral, and 9(0.9%) pericardial ruptures; 49 cases w ere unclassified. Chest (43.9%) and splenic (37.6%) trauma were the mo st common associated injuries. The diagnosis was made preoperatively i n 43.5% of cases, whereas in 41.3% it was made at exploration or at au topsy and on the remaining 14.6% of the cases the diagnosis was delaye d. The mortality was 17% in those in whom acute diagnosis was made, an d the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a hig h index of suspicion, careful scrutiny of the chest roentgenogram in p atients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated eva luation for days after injury is necessary to discern injury in patien ts not requiring laparotomy. Acute diaphragmatic injuries are best app roached through the abdomen, as more than 89% of patients with this in jury have an associated intraabdominal injury. Patients with diaphragm atic rupture presenting in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.