Traumatic Rupture of Diaphragm Rajesh Shah, FRCS, Sabaratnam Sabanathan, FRCS, Alan J. Mearns, FRCS, and Arnit K. Choudhury, FRCS Department of Thoracic Surgery, Bradford Royal Infirmary, Bradford, United Kingdom

Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture: namely, the diaphragmatic hernia. To analyze the clinical and radiologic features and the therapeutic implications, we reviewed 980 patients reported in the English-language literature. This injury affects predomi- nantly males (male:female --- 4:1) in the third decade of life, and is often caused by blunt trauma (75%). There were 1,000 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-sided, 15 (1.5%) bilateral, and 9 (0.9%) pericardial ruptures; 49 cases were unclassified. Chest (43.9%) and splenic (37.6%) trauma were the most com- mon associated injuries. The diagnosis was made preop- eratively in 43.5% of cases, whereas in 41.3% it was made at exploration or at autopsy and on the remaining 14.6% of the cases the diagnosis was delayed. The mortality was

17% in those in whom acute diagnosis was made, and the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdonfinal or polytrauma, and meticulous inspec- tion of the diaphragm when operating for concurrent injuries. Repeated evaluation for days after injury is necessary to discern injury in patients not requiring laparotomy. Acute diaphragmatic injuries are best ap- proached through the abdomen, as more than 89% of patients with this injury have an associated intraabdomi- nal injury. Patients with diaphragmatic rupture present- ing in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.

(Ann Thorac Surg 1995;60:1444-9)

T raumatic rupture of the diaphragm is no longer an uncommon entity. Injuries of the diaphragm often

challenge the surgeon by the subtle presentation in the face of more obvious injuries [1]. A delayed or missed diagnosis at the t ime of initial t r auma and life- threatening catastrophic sequelae of the untreated pa- tients compound the problem. Few topics in surgery of trauma have generated more controversy and publica- tions than that of delayed diagnosis of injuries to the diaphragm. Whether one speaks about acute perfora- tions or tears or chronic posttraumatic hernias, differ- ences of opinion exist as to the most common mecha- nism, relative frequency of left-sided versus right-sided injuries, value of routine chest roentgenogram, diagnos- tic procedures of choice, and operative approach [2]. To answer some of these questions we present a collective review of the literature of 980 patients treated at various centers from 1981 to 1991.

R e v i e w of the Literature

Historical Vignette Traumatic diaphragmatic hernia apparently was de- scribed by Sennertus, who in 1541 reported an instance of delayed herniation of viscera through an injured dia- phragm [3]. Ambroise Par6, in 1579, described the first case of diaphragmatic rupture diagnosed at autopsy. The

Address reprint requests to Dr Sabanathan, Department of Thoracic Surgery, Bradford Royal Infirmary, Duckworth Lane, Brad/ord BD9 6RJ, UK.

patient was a French artillery captain who initially sur- vived a gunshot wound of the abdomen, but died 8 months later of a strangulated gangrenous colon, herni- ated through a small diaphragmatic defect that would admit only the tip of the small finger [4]. It was not until 1853 that antemortem diagnosis of traumatic rupture of diaphragm was made by Bowditch [5]. The first success- ful diaphragmatic repair was reported by Riolfi in 1886 [6] in a patient with omental prolapse, and Naumann [7] in 1888 repaired the defect with herniated stomach. The largest and the most comprehensive collective review was published by Hood in 1971 [8], whereas the earliest review on this subject was by Carter and associates in 1951 [9].

Incidence The reported incidence of diaphragmatic rupture is be- tween 0.8% and 1.6% of the patients admitted to the hospital with blunt t rauma [10, 11]. Because the diagnosis is frequently not obvious and is missed in 7% to 66% of multiply injured patients, the actual incidence may be slightly higher [1, 12-15]. Four to 6% of the patients undergoing laparotomy or thoracotomy for t rauma have diaphragmatic injuries [16, 17].

Etiology Traumatic diaphragmatic rupture results from blunt or penetrat ing thoracoabdominal trauma. Blunt t rauma caused by motor vehicle accidents and penetrat ing t rauma from gunshot and stab wounds are the major

© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50 SSDI 0003-4975(95)00629-Y

Ann Thorac Surg REVIEW SHAH ET AL 1445 1995;60:1444-9 TRAUMATIC RUPTURE OF DIAPHRAGM

etiologic factors in most patients. There are reported cases of iatrogenic diaphragmatic injury, spontaneous rupture during pregnancy, and unexplained spontane- ous rupture [8, 18-20]. Variations in the incidence reflect the demography of the population served [21]. The present collective review suggests 75% of the injuries were due to blunt trauma and 25% were due to penetrat- ing trauma (Table 1) [1, 11, 15, 21-38]. Of the penetrating injuries in the lower thoracic area, 15% of stab and 46% of gunshot wounds had diaphragmatic injuries [32]. Rou- tine laparotomy for all penetrating injuries involving lower chest below the nipple line, abdomen, and back have reduced the delayed diagnosis of diaphragmatic ruptures to 2.9% [36].

Mechanism of Injury The mechanism of injury in penetrating injury is self evident. The actual mechanism or mechanisms of injury causing diaphragmatic rupture remain speculative, but theoretical causes include shearing of a stretched mem- brane [39-41], avulsion of the diaphragm from its points of at tachment [42], and sudden force transmission through viscera acting as a viscous fluid [40, 43]. How- ever, there is no experimental evidence to support any of the hypotheses. Studies on bursting pressure in cadavers showed a consistent weakness on the left side [44]. There is a positive gradient of 7 to 20 cm H20 between intra- peritoneal and intrapleural pressure [45]. This positive pressure gradient can exceed 100 cm H20 during maxi- mum respiratory effort and encourages transdiaphrag- matic herniation of abdominal viscera through the defect [1]. During severe abdominal trauma, a tenfold increase in pressure can occur in the abdomen, transmitting a sudden blow of kinetic energy through the domes of the hemidiaphragm [26].

Left-sided rupture occurred in 68.5% of the patients, 24.2% had right-sided rupture, 1.5% had bilateral rup- ture, 0.9% had pericardial rupture, and 4.9% were unclas- sified in the present collective review. Increased strength of the right hemidiaphragm, hepatic protection of the right side, underdiagnosis of right-sided ruptures, and weakness of the left hemidiaphragm at points of embry- onic fusion all have been proposed to explain the pre- dominance of left sided diaphragmatic injuries [12, 43, 46-48].

Pathophysiology The pathophysiologic effects of ruptured diaphragm are on circulation and respiration. This is due to the impaired function of the diaphragm, compression of the lungs, and displacement of the mediastinum with impairment of the venous return to the heart [24]. In cases of pericardial tear, the heart is compressed by the herniating viscera, and a clinical picture of cardiac tamponade may follow [49]. Diaphragmatic action accounts for two thirds of the tidal volume when supine [50]. Functional loss of one hemidiaphragm results in 25% to 50% decrease in pul- monary function [51].

Diagnosis Multiple classification systems have been used when referring to the natural history of the diaphragm injuries. An especially appropriate system described by Grimes [52] divides the presentation into three phases, the acute phase, latent phase, and obstructive phase. The acute phase extends from the time of original trauma to the apparent recovery from the primary injuries. The latent phase then begins as the intraabdominal viscera occupy the defect and variably herniate into the thoracic cavity. The obstructive phase then begins with the signs of visceral obstruction or ischemia as in other hernias. Carter and associates [9] have shown that in 85% of their cases strangulation occurred within 3 years of the re- sponsible trauma. They also found 90% of the strangu- lated diaphragmatic hernias to be traumatic in origin. Clinical features of the three phases are as follows:

Acute phase Abdominal pain Concurrent injuries

Chest/abdominal wall Hemopneumothorax Intraabdominal organs Pelvis Head Extremities

Respiratory distress Cardiac dysfunction Chest x-ray film abnormality Defect detected at laparotomy

Latent phase Upper gastrointestinal complaints Pain, left upper quadrant or chest Pain, left shoulder Dyspnea Orthopnea Decreased breathing sounds Abnormal chest x-ray film findings

Obstructive phase Nausea and vomiting

Unrelenting abdominal pain Prostration Respiratory distress

Borchardt's triad Mediastinal shift

Strikingly abnormal chest x-ray film findings

The acute phase is dominated by associated injuries, which are present in 95% to 100% of the cases [11]. Hood [8] compiled the data from various series and showed that on average there was an incidence of 1.6 associated injuries per patient, fractured ribs and ruptured spleen being the most common. The incidence of associated injuries in the present review is summarized in Table 1.

The diagnosis of ruptured diaphragm is frequently missed in the acute phase because of the presence of shock, respiratory insufficiency, visceral injuries, and coma. McCune and associates [27] stated that 33% were overlooked during the initial phase, whereas Saegesser

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Table 2. Mode and Timing of Diagnosis

First Preoperative Incidental Delayed Author Diagnosis Diagnosis CXR Diagnosis

Morgan [22] 42% 53% 42% 5% Ilgenfritz [23] 50% 42% 50% .,. Beaucharnp [24] 62.5% 20.8% 62.5% 16.6% Smithers [25] 62.3% 29.4% 60% 8% Troop [15] 35.7% 57% 33.3% 7.1% De la Rocha [26] 41.6% 16.6% 41.6% 33.3% Van Vugt [28] 50% 39.2% 50% 10.7% Ward [11] 25% 68.7% 25% 6.2% Christophi [29] 61.9% 28.5% 61.9% 9.5% Rodriguez Morales 40% 56.6% 40% 3.3%

[301 Sharma [31] 39.2% 60.7% 41% .. . Waldschmidt [1] 68% 29% 15.1% 3.4% Payne [21] 27.7% 11.1% 27.7% 61.1% Broos [32] 46.7% 17.7% 46.7% 35,4% Kaulesar Sukul [33] 31.7% 63.4% 31.7% 4.7% Brown [34] 58.5% 36.5% 58.5% 4.8% Arendrup [35] 51.8% ... 51 .8% 48% Miller [36] 3.9% 93.1% 3.9% 2.9% Carter [37] 43.1% 47.0% 43.1% 9.8% Toh [38] 28.5% 57.1% 28.5% 14.2%

Total 43.5% 41.4% 40.7% 14.6%

CXR - chest roentgenogram.

and Besson found that a diagnosis was not made during the first 3 days in no less than 62% of patients with multiple injuries [27]. The present review suggests that the diagnosis of traumatic ruptured diaphragm was made preoperatively in 43.5 % of the cases, incidentally at laparotomy or thoracotomy or autopsy in 41.3% of the cases and a delayed diagnosis was made in 14.6% of the cases (Table 2). Many investigative techniques have been described for the diagnosis of ruptured diaphragm [28]:

Chest roentgenogram Chest roentgenogram with nasogastric tube in situ Roentgenographic contrast studies Radioisotopic scintigraphy of liver and spleen Angiography Ultrasonography Computed tomographic scan Thoracoscopy Pneumoper i toneography and lavage Peritoneal lavage and contrast study Laparoscopy

In most instances careful examination of adequate chest roentgenograms will suffice [53]. To add diagnostic effi- cacy, this can be repeated after the passage of a ra- diopaque nasogastric tube or simple contrast studies of the upper gastrointestinal tract. In the present review diagnosis on the basis of the chest roentgenogram was made in 40.7% of the cases. Diagnostic signs, either pathognomonic or suggestive on chest roentgenogram, are as follows [28]:

Pathognomonic Gas bubbles in the chest Nasogastric tube in the chest Positive Gastrografin study

Suggestive Irregularity of the diaphragmatic outline Elevated diaphragm Mediastinal shift without pulmonary or intrapleural

cause Compression atelectasis of the lower lobe

There appear to be too many false negatives to depend on diagnostic peritoneal lavage for diaphragmatic dam- age after blunt trauma. Several workers record a false- negative rate of approximately 25% [30, 54, 55]. The diagnosis of traumatic diaphragmatic hernia is not al- ways easily made. Specialized techniques as mentioned above may be used, but t ime-consuming procedures may provide an additional risk to traumatised patients and cause a delay in adequate management . Computed to- mographic scanning is a useful aid in the diagnosis of urgent cases [56]. Adamthwaite [57l advised thoracos- copy in the acute phase within 24 hours of injury. In cases seen after more than 24 hours and in all delayed chronic cases where other diagnostic methods have failed to demonstrate the lesion, laparoscopy provides a means of diagnosis.

Management Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concur- rent injuries. Repeated evaluation hours and days after injury may be necessary to discern injury in those pa- tients not requiring laparotomy [49].

ACUTE INJURY. Patients with diaphragmatic injury require standard resuscitation and evaluation, including airway control and ventilation as well as restoration of circula- tion by stopping external hemorrhage and effective vol- ume restoration. The military antishock trousers (MAST) should not be applied to those patients suspected of having diaphragmatic damage as it could result in dra- matic cardiopulmonary deterioration ]58]. As soon as the patient has been evaluated and stabilized as much as is practical, the associated injuries require prompt opera- tive attention. In the uncommon case of massive hernia- tion into either pleural space or luxation of the heart, the diaphragmatic injury requires urgent attention. Al- though there have been advocates of thoracotomy versus laparotomy for some years, a minority still espouses thoracotomy as the preferable route, especially for right- sided lesions [55, 59]. The majority of the patients have associated intraabdominal injuries [1]; consequent ly most writers, including Drews and co-workers [16] as well as Waldschmidt and Laws [1], recommend laparot- omy as the preferable approach. In the latter series involving 86 patients, only 1 patient of 65 undergoing initial laparotomy required a thoracotomy. Of the 15 undergoing initial thoracotomy, 7 needed a subsequent

1448 REVIEW SHAH ET AL Ann Thorac Surg TRAUMATIC RUPTURE OF DIAPHRAGM 1995;60:1444-9

laparotomy [1]. If the repair of right-sided injury is difficult from the abdomen, extension of the abdominal incision into the chest (thoracoabdominal) or a separate thoracic incision can be considered to facilitate repair [60]. It is imperative that the diaphragm is sutured in two layers with interrupted, large, nonabsorbable sutures [28, 49].

LATENT AND DELAYED CASES. Concurrent, acute intraab- dominal injury should be manifest immediately or cer- tainly within 48 hours. A diaphragmatic injury may become evident after this time or even much later. A delayed repair within the first few days can be done by a laparotomy or a thoracotomy. On the right side a thora- cotomy is preferable. After about 7 to 10 days, there may be intrathoracic adhesions of the herniated abdominal organs, and the preferable approach should be a thora- cotomy on the affected side [49].

Mortality Mortality rates vary from 1% to 28% in the literature. This collective review reflects mortality of 17%. Invariably the associated injuries are responsible for the high mortality. Pulmonary complications head the list of complications in the group undergoing operation [30, 31].

Conclusion

Young males are the usual victims of traumatic rupture of the diaphragm, indicating their involvement in motor vehicle accidents and violence. Blunt t rauma is the usual cause in the majority of the cases, although penetrat ing injury is responsible in one fourth of the cases. The left-sided injury predominates, although the incidence of r ight-sided injur ies is increasing. Chest in jury and splenic injuries are the most common associated injuries. A high index of suspicion, careful scrutiny of t he chest roentgenogram, and meticulous inspection of the dia- phragm at operation serve to detect most acute cases. In most subtle instances without associated injuries that force operation, additional steps may be required to establish the diagnosis. These include repeat chest x-ray films, computed tomographic scan, bar ium contrast stud- ies, laparoscopy, and radionuclide studies. Laparotomy is the operative approach of choice in acute situations; thoracotomy on the affected side is the best choice for chronic or delayed cases. Associated injury is responsible for the high mortality and morbidity, chiefly because of pu lmonary complications.

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