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A woman in her 40s self-presented to an emergency department in a major trauma centre with severe right-sided abdominal pain, a tender right upper quadrant mass and chest pain. Diagnostic imaging showed a previously undiagnosed diaphragmatic hernia containing strangulated right colon. The patient had been the victim of a high-energy road traffic accident 18 months earlier, but at that time had not presented to hospital or undergone any outpatient investigation. This emergency presentation necessitated an emergency laparotomy, right colectomy, suture repair of diaphragmatic hernia and formation of ileo-colostomy. While a small number of similar cases have been documented, right-sided traumatic diaphragmatic herniae (TDH), where abdominal viscera bypass the liver and subsequently strangulate, are exceedingly rare. The evidence on delayed diagnosis of TDH is discussed and a system of follow-up for patients who suffer blunt abdominal trauma which is managed non-operatively is suggested., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background: The incidence of diaphragmatic rupture is low; however, it may be life threatening. Normally caused by blunt trauma, some cases are reported after pulmonary infections with extensive coughing. Covid 19 causes pulmonary infections and pneumonia and has been associated with weakening of the diaphragm after prolonged ventilation. We present a patient who suffered from diaphragmatic rupture 2 months after recovering from a severe Covid 19 pneumonia., Case: A 71 years old male patient presented with massive thoraco-abdominal pain and severe dyspnea. At the time of admission, the patient was diagnosed with rupture of the diaphragm and developed cardiogenic shock. Intraoperatively there was a 4 cm diameter large rupture of the diaphragm with enterothorax (transverse colon, stomach, spleen, parts of the jejunum). Avulsion of the mesenteric arteries made a segmental resection of the jejunum together with the spleen necessary. A jejuno-jejunostomy was performed and organs were replaced into the abdomen. The rupture of the diaphragm underwent primary closure with non-resorbable suture material. The patient has shown an uneventful post-operative course, fully recovered and was discharged on day 11 after surgery., Conclusion: Covid 19 is a disease that is known to have various effects on different organs. The diaphragm is only paid heed in case of dysfunction. Also in the setting of Covid 19 it is not known as prominent effector organ. Nevertheless its affection by coughing caused by Covid 19 can lead to life threatening complications., (© 2022. The Author(s).)

Background: This report reviews our clinical experience with 55 cases of traumatic diaphragmatic hernia at a Brazilian university hospital. Traumatic diaphragmatic hernia is an uncommon injury and presents diagnostic and therapeutic challenges. Occasionally, it is missed in trauma patients and is usually associated with significant morbidity and mortality. This analysis aimed to improve the diagnostic outcomes of trauma patient care., Methods: Retrospective design analysis of database records of trauma patients at HC-Unicamp were performed to investigate incidence, trauma mechanism, diagnosis, herniated organs, associated injuries, trauma score, morbidity and mortality., Results: Fifty-five patients were analysed. Blunt trauma was two-fold more frequent than penetrating trauma and was associated with high-grade injury; motor vehicle collision was the most common mechanism. Left-sided hernia was four-fold more frequent than that on the right side, although critical injuries were more frequently associated with the right side. The stomach was the most herniated organ in both trauma mechanisms. Preoperative diagnosis was mostly performed using chest radiography (55%). Postoperative diagnosis was mostly performed via laparotomy rather than laparoscopy. Associated injuries were observed in 43 patients (78%) and the mortality rate was 20% for both the sides., Conclusion: Isolated injuries are rare, and the presence of associated injuries increases morbidity and mortality. Chest radiography in the trauma bay is useful as an initial examination, although it is not suitable for use as a definitive method. Despite the use of laparoscopy in a few cases, laparotomy is the most common approach., (Copyright© Authors.)

Background: Traumatic diaphragmatic hernia (TDH) is rare in children, most often occurring following blunt thoracoabdominal trauma from high energy mechanisms, such as motor vehicle collisions (MVC). We performed a systematic review to describe injury details and management., Methods: Following PRISMA guidelines, a systematic literature search was performed to identify publications of blunt TDH in patients < 18 y old. Conflicts were resolved by consensus. Data were collected on demographics, TDH location, mechanism of injury, associated intraabdominal injuries (IAI), management, and outcomes. Denominators vary depending on number of patients with such information reported., Results: Fifty-eight articles were reviewed with 142 patients with TDH. The median age was seven y (range 0.25-16). Most were left-sided (85 of 126, 67.5%). MVC was the most common mechanism (66 of 142, 46.5%). IAI was present in 50.0% (57 of 114), most commonly liver injuries (25 of 57, 43.9%). Delayed diagnoses occurred in 49.6% (57 of 115, range 8 h-10 y), and were more common with right-sided TDH (76.0% versus 48.5%, P = 0.02). Chest radiography was 59.0% sensitive for TDH, while computed tomography sensitivity was 65.8%. Operative repair was performed on all surviving patients, and all underwent primary diaphragm repair. The overall mortality was 11.3% (n = 16), with four attributable to the TDH. There were no reported recurrences over a median follow-up of 12 mo., Conclusions: Pediatric TDH is a rare diagnosis with a high rate of associated IAI and delayed diagnosis. Primary diaphragm repair was performed in all cases. Surgeons should maintain a high suspicion for diaphragm injury in blunt thoracoabdominal trauma., (Copyright © 2021. Published by Elsevier Inc.)

Thoracoabdominal hernia following blunt trauma is extremely rare. Abdominal viscera are more likely to herniate into the thorax if there is traumatic diaphragmatic rupture. We report the case of a patient presenting with a traumatic thoracoabdominal hernia containing part of the right lobe of the liver and the hepatic flexure of the colon. The hernia migrated cranially, to protrude through a seventh intercostal defect despite the diaphragm remaining fully intact. The need for early multispecialty (thoracic and hepatobiliary) surgical repair is highlighted, with improvements in surgical outcome for a complex trauma case by using a novel chest-wall reconstruction technique.

Blunt chest trauma followed by diaphragm rupture is a severe injury requiring surgical correction both in acute and long-term periods. Posttraumatic diaphragmatic hernia is dangerous by infringement of dislocated organs. Thanks to adaptive mechanisms of the organism, patients with non-functioning half of the diaphragm have a good quality of life for a long time. Symptoms (respiratory disorders and arrhythmia, predominantly) occur over time in patients with concomitant diseases and impaired function of vital organs. At the same time, simultaneous thoracic and abdominal surgery is possible. Thoracotomy is advisable for injury of the right half of the diaphragm, thoracotomy and laparotomy - for injury of the left half. It is presented case report of diaphragm repair by primary suture without application of strengthening materials in 17 years after complex trauma. In this case, diaphragm function was restored that resulted improved quality of life.

The patient was an emergency transported, 57-year-old man complaining of left thoraco-lateroabdominal pain, with a history of blunt chest trauma 3 months prior. Thoracoabdominal computed tomography (CT) resulted in a diagnosis of diaphragmatic hernia with incarceration and perforation of the stomach, and same-day emergency surgery was performed. The surgery was performed via an abdominal approach, and after manually repositioning the stomach incarceration, the perforated region was resected and the diaphragm sutured closed. Diaphragmatic hernia can be occasionally difficult to diagnose at the time of initial treatment, and may have been overlooked at the initial presentation, 3 months earlier in the present case. When examining a case of blunt force thoracoabdominal trauma, it is important to keep in mind the possibility of diaphragmatic injury. Additionally, during surgery for traumatic diaphragmatic hernia, in cases where manipulation of the abdominal organs is thought necessary, commencing the surgery with an abdominal approach is desirable.

Traumatic diaphragmatic hernias could be clinically apparent and diagnosed after months and years after trauma. Bilateral ruptures of the diaphragm rarely appeared. Patients (46 cases) with diaphragmatic hernias were treated at the period from 1998 to 2010. The rate of diaphragmatic hernias consisted of 41,3%, bilateral post-traumatic hernias was noted in 2.2%. The article presents a follow-up study of bilateral diaphragmatic hernia, which was formed on the left (after 1 year) and on the right after 5 years. Diagnosis was supported by radiographic contrast research and computed tomography data. The stomach and omentum were displaced to the pleural cavity on the left, the transversely colon and omentum had a shift on the right. Thoracotomy and diaphragm plasty were performed in both cases. Hernial orifice was located in the area of esophageal opening and crura of diaphragm. It is necessary to increase clinical suspicion in relation to possibility of diaphragmatic hernia origin after severe closed trauma.

Traumatic right diaphragmatic hernia is rare in children. Its diagnosis can be difficult in the acute phase of trauma because its signs are not specific, especially in a poly trauma context. We report two cases of traumatic right diaphragmatic hernia following a blunt thoraco-abdominal trauma, highlighting some difficulties in establishing an early diagnosis and the need for a high index of suspicion.

The authors report the case of a 63-year-old patient who was polytraumatized in a motor vehicle accident and suffered multiple traumatic injuries. Chest and pelvic fractures as well as left-sided diaphragmatic rupture with associated omentum herniation were diagnosed on CT scan. None of the injuries required urgent surgical intervention. After 10 days supportive therapy, elective laparoscopic reconstruction of the diaphragmatic hernia was performed. The authors discuss the role of laparoscopic diaphragm reconstruction.

Introduction: Intrapericardial diaphragmatic hernia is a rare injury. We present a case of an intrapericardial diaphragmatic hernia from blunt trauma. In this report we will review the current literature and also describe the first report of a primary laparoscopic repair of the defect., Case Description: A 38-year-old unrestrained male passenger had blunt chest and abdominal trauma from a motor vehicle collision. Two months later, on a computed tomography scan, he was found to have an intrapericardial diaphragmatic hernia. The defect was repaired primarily through a laparoscopic approach., Discussion: Symptoms of intrapericardial diaphragmatic hernia are chest pain, upper abdominal pain, dysphagia, and dyspnea. Chest computed tomography is the most useful diagnostic test to define the defect. Even when the injury is diagnosed late, laparoscopy can be used for primary and patch repair.

Diaphragmatic rupture is usually an immediate, left-sided complication of high-velocity thoraco-abdominal trauma. Here we present a rare case of delayed, right-sided diaphragmatic rupture and its laparoscopic mesh repair.

Diaphragmatic ruptures after blunt trauma are rare life-threatening conditions. Most of them occur on the left-sided hemidiaphragm with herniation or associated organ injuries after a motor vehicle accident. We present an unusual case of blunt diaphragmatic rupture resulting in a delayed hemothorax. A 62-year-old man presented with acute dyspnea that initiated while straining to pass stool. He had a bruise on the lower back region of his right thorax after a slip-and-fall accident 7 days previously. Chest computed tomographic scans revealed a right-sided hemothorax without any evidence of herniation or associated organ injuries. Emergency surgery was performed through a video-assisted minithoracotomy. During surgery, we identified a diaphragmatic laceration with a severed blood vessel originating from the right superior phrenic artery. The lesion was repaired with interrupted horizontal mattress sutures. The total amount of bleeding was approximately 2000 mL. The patient had an uneventful recovery with no further bleeding episodes.

Background: Tension viscerothorax is herniation of abdominal viscera into the thorax. Tension viscerothorax can simulate tension pneumothorax. Immediate decompression with a nasogastric tube is required for hemodynamic stabilization., Objective: A case of tension viscerothorax is reported along with a review of the literature to highlight this rare complication of blunt abdominal trauma, and to emphasize the importance of nasogastric tube decompression in tension viscerothorax., Case Report: A 10-year-old boy with a remote history of trauma related to a motor vehicle crash was brought into the Emergency Department with a 3-day history of vomiting, epigastric pain, and dyspnea. By physical examination and chest X-ray study, tension gastrothorax was diagnosed. Nasogastric tube placement was difficult and delayed, and the patient deteriorated into cardiac arrest, but after successful cardiopulmonary resuscitation and nasogastric tube insertion, the patient was stabilized. Laparotomy was performed and primary repair of a ruptured diaphragm was done. The patient made an uneventful recovery., Conclusion: Acute tension viscerothorax should be considered in the differential diagnosis of tension pneumothorax, and its initial resuscitation should include nasogastric tube insertion for immediate decompression., (Published by Elsevier Inc.)

We report a rare case of traumatic transdiaphragmatic intercostal hernia (TDIH) in an 85-year-old women who was transported to our hospital by ambulance after blunt trauma caused by the involvement in a motor vehicle accident. Chest and abdominal computed tomography (CT) revealed a left diaphragmatic rupture with a chest wall hernia involving loops of small intestine. An emergency operation was performed and led to a diagnosis of TDIH. Surgery via a thoracoabdominal incision in the left side was performed to reduce the hernia contents, and the diaphragmatic and intercostal defects were reconstructed by direct suture. CT scans were very helpful in detecting TDIH in this case.

We present a rare case of individual but simultaneous rupture of the left pericardium and diaphragm in a patient with multiple blunt trauma. Skeletal trauma was repaired uneventfully with internal plate fixation. Diaphragmatic rupture was suspected and diagnosed 13 days from the initial trauma when the patient exhibited chest pain, dyspnea, and nausea. Intraoperatively, a pericardial rupture was discovered along with subluxation of the heart and repaired with a mesh., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Blunt diaphragmatic injuries are usually caused by blunt trauma or penetrating injuries. The diagnosis may be delayed or missed because of the confusing clinical and radiographic findings and the presence of multiple associated injuries. We report the case of an isolated right diaphragm rupture in a 56-year-old man who sustained blunt thoracic trauma after car accident 2 weeks before presentation. No other injuries were detected, and he was subjected to laparotomy. Diaphragmatic rupture is perceived as an emergency entity. The late appearance of such an injury, without other accompanying injuries, is rare and should be in mind by clinicians treating trauma patients who have a delayed presentation after the injury.

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.

Introduction: Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. We reviewed our institution's management of patients with diaphragmatic rupture after blunt trauma., Methods: All patients in this study were treated at Tan Tock Seng Hospital, Singapore, from March 2002 to October 2008. Patients with penetrating injuries were excluded. The parameters included age, mechanism of injury, haemodynamic status at admission, Glasgow coma scale (GCS) score, injury severity score (ISS), imaging studies, location of diaphragmatic injuries, associated injuries and outcome., Results: 14 patients with a median age of 38 years formed the study group. Vehicular-related incidents accounted for 71.4 percent of the injuries. The median GCS score on admission was 14 (range 3-15), while the median systolic blood pressure and heart rate were 94 (range 50-164) mmHg and 110 (range 76-140) beats per minute, respectively. The median ISS was 41 (range 14-66). All had chest radiographs performed in the emergency department, six (42.9 percent) had computed tomography performed before surgery, while the remaining eight (57.1 percent) were sent straight to the operating theatre from the emergency department. There were five (35.7 percent) right-sided and nine (64.3 percent) left-sided diaphragmatic ruptures. The mortality rate was 35.7 percent. Some of the associated injuries included eight (57.1 percent) splenic lacerations, five (35.7 percent) haemothorax and lung injuries, four (28.6 percent) bone fractures and three (21.4 percent) liver lacerations. 12 (85.7 percent) patients underwent repair of the diaphragmatic rupture using interrupted polypropylene suture, while the remaining two (14.3 percent) were too haemodynamically unstable to undergo definitive treatment. Advanced age, haemodynamic instability and raised ISS were associated with mortality., Conclusion: An accurate diagnosis of diaphragmatic rupture in trauma patients is difficult, and a thorough examination of both the hemidiaphragms is mandatory during emergency laparotomy for these patients. Those with more severe injuries and decreased physiological reserves usually fare worse.

Diaphragmatic hernias are well-known sequelae of abdominal and chest wall trauma. However, they may go undiagnosed in the acute setting but present later due to gastrointestinal or respiratory complications. A distinctive presentation of a diaphragmatic hernia 15 years after a traumatic insult is herein described. Management strategies are also discussed.

Diaphragmatic rupture after blunt trauma is rare, but indicates a powerful external impact. Associated lesions are often life-threatening and require a rapid diagnosis and management. We report a case of a 24-year-old man, admitted to the emergency department after a serious car accident. He complained of a left sided thoraco-abdominal pain with breathing difficulties. Chest X-ray showed a left diaphragmatic elevation. Computed tomography demonstrated a left haemo-pneumothorax, herniation of the stomach in the chest and a haemoperitonium. Laparoscopically, herniated organs were re-integrated in the abdominal cavity ; the diaphragmatic tear was repaired by both direct suture and synthetic prosthesis. Closure of a small bowel perforation found during the laparoscopic exploration was also performed. We consider this therapeutic modality to be an excellent approach in the management of acute left side diaphragmatic rupture in haemodynamically stable patients. Firstly, it permits an inspection of the thoracic cavity through the diaphragmatic tear and secondly, an easy repair of damaged structures in the abdominal cavity.

Introduction: Post-traumatic diaphragmatic hernia is a particular lesion in traumatology that may be neglected. Thus, the diagnosis may be delayed for a few days to several months and only be made following a complication. The left diaphragmatic cupola is the most touched. Tension fecopneumothorax following diaphragmatic hernia perforation in the pleural cavity is a rare but particularly severe complication of traumatic diaphragmatic hernia., Case Report: A 68-year-old man was admitted for acute intestinal occlusion with respiratory distress. A history of a violent blunt thoraco-abdominal traumatism resulting from a traffic accident eight years before was noted. The chest x-ray revealed an abundant hydropneumothorax and the thoracic scan revealed abundant effusion with heterogeneous density in the left pleural cavity, associated with an intrapleural hernia of the large intestine. An emergency thoracolaparotomy discovered tension fecopneumothorax secondary to intrathoracic perforation of the transverse colon through a left hemidiaphragm defect. The surgical treatment consisted of hernia reduction, pleural drainage, colostomy and repair of the diaphragmatic defect., Conclusion: The possibility of diaphragmatic hernia should be kept in mind in case of violent blunt thoraco-abdominal traumatism or basithoracic wound. In this way, complications such as tension fecopneumothorax that could threaten the functional and vital prognosis may be prevented.

A right diaphragmatic rupture (RDR) after blunt trauma is rare. Diagnosis of this entity remains difficult due to the absence of a precise anamnesis and pathognomonic signs. We report two cases of acute and latent RDR respectively. Immediate laparotomy was performed in the first case and thoracotomy was done nine weeks after blunt trauma for the second one. After the hepatothorax reduction, diaphragmatic lesions were sutured and reinforced by prosthesis. Acute RDR evolve inevitably to a latent and obstructive phases. Then, the mainstay treatment is surgical repair of the diaphragmatic defect. At present, thoracotomy is recommended for latent RDR. In the acute phases, thoracic and/or abdominal approaches depend on associated lesions, hemodynamical patient stability and surgical competence of the practitioner.

Background: Blunt diaphragmatic rupture (DR) is a rare condition usually masked by multiple associated injuries, which are the main cause of morbidity and mortality. The overall incidence of diaphragmatic injury is 0.8-5.8% in blunt trauma--2.5-5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. A correct diagnosis remains difficult and is usually made late., Methods: Over four years 12 patients with blunt DR were treated in our hospital. Their charts and X-rays were analyzed. All the surgeons involved were interviewed. Diagnostic and treatment modalities were analyzed and discussed., Results: Acute diaphragmatic rupture (ADR) was diagnosed in nine patients within seven days. Three patients presented with bowel obstruction and post-traumatic diaphragmatic hernia was diagnosed intraoperatively. Nine patients had rupture of the left hemidiaphragm, two had rupture of the right hemidiaphragm, and one had bilateral DR. Diagnosis of DR was made in all patients in the ADR group before surgery. The correct diagnosis was made within 12 h by junior medical officers in 66.6% of cases. Two patients were diagnosed on a second chest X-ray in response to progressive respiratory distress. The diaphragmatic defect was repaired in all patients via laparotomy; only one patient required additional thoracotomy. Mortality was 25%., Conclusions: Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases of DR. Respiratory distress should be treated with intubation as intercostal drainage (ICD) may not improve the situation and is associated with a high risk of iatrogenic injuries. Surgical repair is mandatory and laparotomy should be the preferred approach in unstable patients. To avoid missed injury thorough inspection of both hemidiaphragms should be done routinely on every trauma patient undergoing laparotomy. It is widely recommended to use non-absorbable suturing for diaphragm repair but slowly absorbable material seems reliable also.

Diaphragmatic, lumbar, and extra-thoracic hernias are well-described complications of blunt trauma. However, in the absence of an immediate indication for surgery in the injured patient, early recognition of these hernias can be a diagnostic challenge and delayed presentation is common. Upon diagnosis, surgical repair is necessary secondary to the high morbidity and mortality associated with herniation and strangulation of abdominal organs. Surgical treatment of these hernias is evolving and a variety of options are available to the surgeon. This article will provide a historical overview of post-traumatic diaphragmatic and multi-cavity hernias, and a review of the literature addressing key issues of diagnosis and management.

Thoracic trauma represents an important cause of morbidity in mortality after injury in human beings and animals. After any form of suspected chest wall trauma, initial emergency management should include assurance of a patent airway and adequate ventilation, along with treatment for shock if present. As with any open wound, tetanus prophylaxis should be instituted. Types of trauma to the thoracic region of the horse include pectoral and axillary lacerations, penetrating chest wounds, flail chest, fractures of the ribs, blunt thoracic trauma, and several potential sequelae that include pneumothorax, pneumomediastinum, hemothorax, pleuritis, fistulae of the sternum or ribs, and diaphragmatic hernia. Emergency management of these various forms of thoracic trauma is discussed.

A 62-year-old male who had had the left femoral neck fracture due to a traffic accident 1 year earlier was admitted to our hospital because of abdominal pain. He was diagnosed with a left traumatic diaphragmatic hernia due to the previous traffic accident; his condition was also complicated by shock because the mediastinum was compressed by his severely dilated stomach. We performed an emergent operation. A thoracotomy revealed a large defect, about 5 cm in size, at the central tendon of the left diaphragm and a severely dilated stomach in the left thoracic cavity. The ruptured diaphragm was closed directly after reduction of the stomach.

Acute right-sided diaphragmatic ruptures are rare in children. We report a case of traumatic right-sided diaphragmatic rupture in a child that was managed by delayed repair. The clinical presentation and importance of making an accurate diagnosis and confirmation of any associated visceral injury before definitive surgery is highlighted.

A 45-year-old man, with severe thoracic injury from a motor accident, is reported with traumatic aortic dissection type B and projection of the liver into the thoracic cavity due to a large rupture of the right hemidiaphragm. The patient was successfully managed with endoluminal stent placement in the descending thoracic aorta, and right thoracotomy for the repair of the diaphragmatic hernia. His postoperative course was uneventful. The co-existence of aortic traumatic dissection and right diaphragmatic rupture in trauma patients has never been reported in the literature previously, to our knowledge. Furthermore, the initial x-ray examination findings advocated injury of the right hemithorax and could be misleading. The diagnostic assessment must have a high index of suspicion, whereas the surgical manipulation needs to be fast and targeted to the major thoracic injuries of the patient.

Background: Indirect diaphragmatic rupture (DR) is defined as acquired complete split of the diaphragm after blunt trauma and occurs in 1-5% of massively traumatized patients. The diagnosis is often difficult. However, particular trauma mechanisms and associated injuries may suggest the existence of DR., Methods: A retrospective study was done of 21 consecutive patients from 1993 to 2004 at an university hospital., Results: This study revealed a striking combination of DR with pelvic fractures (12/21, 57%). Of 19 polytraumatized patients, diagnosis was made initially in 13 (68%) and with a delay in six (32%). Right-sided injuries were common (8/21, 38%). Thus a 'protective' function of the liver does not exist. Diaphragmatic rupture can be missed in ventilated patients until extubation leads to herniation of abdominal organs into the thorax., Conclusions: Diaphragmatic rupture should be excluded in all severely abdominally traumatized patients, in particular those with concomitant pelvic fracture. Computed tomography with oral contrast medium is diagnostic in most cases. Access by laparotomy should be preferred after acute trauma, since additional intra-abdominal injuries are frequent.

Background/aims: Severe blunt torso trauma can cause diaphragmatic rupture. Such trauma remains a diagnostic challenge to the trauma surgeon, particularly when the initial chest roentgenogram is unrevealing. Owing to age, preexisting diseases, and poor physiological reserves, elderly patients suffer higher mortality rates after trauma than young patients. The difference between elderly and young patients in terms of blunt diaphragmatic rupture is particularly interesting., Methodology: Records from 78 patients presenting with blunt diaphragmatic rupture at our hospital from July 1992 to January 2001 were retrospectively reviewed. Age, gender, co-morbid disease, trauma mechanism, associated organ injury, injury severity score, hemodynamic status on arrival at our Emergency Room, injury side and size of diaphragmatic rupture, delay before operation, and postoperative complications and mortality were determined for elderly (> or = 65 years) and young (<65 years) patients., Results: 10 elderly and 68 young patients were collected and reviewed. Elderly patients had higher rate of preexisting disease (60% vs. 16.2%), associated injury of long bone fracture (60% vs. 23%), and initial normal chest roentgenogram (50% vs. 12%) and they had significant delays before operation. Only 20% of elderly patients were operated on within 24 hours of trauma, compared to 87% of young patients, and 50% elderly patients were actually operated on over a week after the trauma. Furthermore, no statistically significant differences existed between elderly and young patients in ISS (19.9 +/- 6.3 & 22.8 +/- 10.4), or the injury side of diaphragmatic rupture, although elderly patients did display shorter diaphragmatic ruptures (5.6 +/- 3.3 & 10.0 +/- 6.0cm, p<0.05), and longer periods on postoperative ventilatory support (17.7 +/- 21.2 & 3.2 +/- 5.0 days, p<0.05). Finally, elderly patients also had significantly higher rates of postoperative complications of pneumonia (30% & 5.9%), and mortality (50% & 2.9%) than young patients did., Conclusions: Compared to young patients, elderly patients with blunt diaphragmatic rupture had significantly higher rates of initial normal CXR, partly due to shorter length of diaphragmatic rupture, and partly due to ventilatory support, and consequent higher rate of delays before surgery. Furthermore, they also needed longer postoperative ventilator help, and prevailed higher rates of co-morbid disease, postoperative pneumonia, and mortality. Careful initial investigation and prudent radiological follow-up is recommended for elderly patients with severe blunt torso trauma.

A 67-year-old man was referred to our department, after a vehicle accident, with multiple bone fractures and a left blunt diaphragmatic rupture. An emergency laparatomy was performed, and the left diaphragmatic defect directly sutured. Postoperatively, a delayed right diaphragmatic rupture occurred due to progressive inflammation and muscle devitalisation. The diagnosis was challenging because the right rupture became clinically evident later after extubation. Diaphragmatic reconstruction was performed through a right thoracotomy. A high index of suspicion should always be observed for missed or delayed bilateral diaphragmatic ruptures.

The Authors studied 30 cases of diaphragmatic traumatisms from 1972 to 2003 to stress the difficulty to achieve an early diagnosis and the need of their immediate treatment: 26 of these patients were male and 4 female (6.5:1); the pathogenesis was in 50% of cases an open trauma and in 50% a closed trauma. The mean age was 36.6 years (33.4 in the open trauma and 41.4 in the closed). The left hemi-diaphragm was affected more frequently (63%) than the right (37%). The associated lesions were mainly of the parenchymatous abdominal organs (spleen 43.3% and liver 49%), while in the thorax lung was involved in 20% of cases and heart in 3.3%. All patients underwent plastic surgical intervention of the diaphragm. In only one case, particularly severe, the operation consisted in placing a pleuric drain and death occured a few hours later. Mean mortality was 30% (33.3% in open and 26.6% in closed traumas) and mean hospital stay was 36.2 days. Accurate diagnosis in emergency is difficult because of the frequent associated lesions, typical of these patients. Despite of the optimisation of the rescue and the new imaging technologies, the gold standard for treatment is not yet reached. There is still a considerable amount of misdiagnosis, a relevant mean hospitalization, a high mortality and a very high morbidity. The best approach to thoraco-abdominal traumas is still to fear a diaphragmatic lesion up to contrary demonstration, in order to achieve precocious diagnosis and surgical treatment, to avoid complications of delayed treatment.