Blunt diaphragmatic rupture

Objective: To identify (1) predictors of outcome in blunt diaphragmatic rup ture (BDR), and (2) factors contributing to diagnostic delay. Methods: We r eviewed the charts and radiographs of 41 patients with BDR treated in our H ospital 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%). Results: Two groups of patients can be identified: group A (n = 36, 88%) with acute BDR, and group B (n = 5, 12%) with posttraumatic diaphragmatic hernia (TDH). In group A, immediate diagno sis 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 w eeks later. Associated injuries were present in 34 patients (94%) involving : spleen (n = 18), rib fractures (n = 17), liver (n = 14), lung (n = 11), b owel (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 thr ough 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 bilat eral BDR died. The patients who died were older than the survivors (mean ag e: 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 T DH, diagnosis was delayed for 7-16 months after injury. Four patients had n on-specific clinical signs and one strangulation of hollow viscera. One pat ient had undergone surgery during acute injury but BDR was overlooked. Loca tion of TDH was on the left in three cases and on the right in two. Delay i n 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 enc ountered. Conclusions: (1) Predictors of BDR mortality are: age, ISS and he modynamic 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, wh ere a thorough examination of both hemidiaphragms is mandatory. A high inde x of suspicion combined with repeated and selective radiologic evaluation i s necessary for early diagnosis. (C) 1999 Elsevier Science B.V. All rights reserved.