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From 1968 to 1980 we have treated 21 patients with a rupture of the diaphragm due to blunt trauma. The diagnosis was generally made in the acute phase. Right-sided rupture in this series accounted for 24% of cases. This figure differs significantly from the 10% incidence mentioned in the literature. In our opinion right-sided rupture, especially in patients with multiple injuries, is often overlooked.

Summaries of two patients who were not operated upon because they seemed to have only minor upper abdominal stab wounds are presented. Both patients later developed symptomatic diaphragmatic hernias for which operation was required. These patients illustrate a shortcoming of the selective method of management of upper abdominal stab wounds and suggest that diagnostic paracentesis and peritoneal lavage should be employed regularly in patients who do not have a clear indication for laparotomy.

A review of ten years of experience with traumatic diaphragmatic hernia, an often-missed injury, is presented. The unusual occurrence of a right diaphragmatic hernia following blunt trauma, which occurred in one patient, prompted this retrospective review. A high index of suspicion is still a safeguard against missing this injury. The mechanism of diaphragmatic tear with blunt trauma is described and modes of diagnosis and treatment are discussed.

The etiology, diagnosis and management of traumatic diaphragmatic hernias were discussed, and a personal series of 61 hernias was reviewed. The need for a greater clinical awareness of the condition was stressed. Chest roentgenograms were shown to be the most effective diagnostic method, and thoracoscopy was recommended in all hernias that occurred within 24 hours of the injury. Barium contrast studies of the gastrointestinal tract have limitations, and caution was advised with these methods when dealing with patients presenting in acute crisis. Computerized tomographic scanning is becoming increasingly more valuable in the investigation of this condition, but the author hesitates to recommend its routine use. A plea was made for the abdominal approach to diaphragmatic hernias. The value of this approach was illustrated by the successful repair of 58 of 61 hernias through a laparotomy.

The writers report a clinical series of 50 patients with traumatic diaphragmatic hernia. There were 36 hernias on the left side and 14 on the right. Stab or bullet wound was the cause of the hernia in 27 cases. The other 23 cases were due to traffic accidents or other blunt injuries. Immediate operative repair was done in 30 cases; in 20 cases the operation was carried out after a time interval of 11.5 years post trauma on an average. Plain chest X-ray, barium meal or enema and pneumoperitoneum were the most valuable diagnostic tools. Visceral injuries were discovered in 53% of cases caused by traffic accidents. The omentum, stomach, colon and spleen were the organs most frequently herniated. In two cases perforation of the stomach occurred before the operation. There were three cases of pericardial rupture associated with the diaphragmatic hernia in the series. The repair was done via thoracotomy in 28 cases, via laparotomy in 4 cases; and both thoracotomy and laparotomy were carried out in 18 cases. The hospital mortality was 2%. One of the patients died of peritonitis and renal failure following perforation of the stomach and intestines on the 9th postoperative day. Recurrence of the hernia occurred twice in one case. Re-examination revealed striction of the diaphragmatic movement in 11 cases. The clinical features, diagnosis and operative treatment are discussed.

Diaphragmatic disruption is an uncommon consequence of blunt trauma and is easily overlooked unless a high index of suspicion is maintained. The diagnosis is important because of the high incidence of associated organ damage and the complications of a missed injury. This article outlines the clinical features and management of the condition.

During the period of 1959 to 1975 34 patients were operated at the Chirurgische Universitatsklinik Koln-Lindenthal because of lesions of the diaphragm. From the survivors 20 patients were examined again 2 to 15 years after operation. 15 patients (75%) stated subjective complaints. On these patients cicatrizations in the sinus phrenicocostalis, higher position of the diaphragm, axial hernia of the hiatus, restricted flexibility of the diaphragm, flattened diaphragm and paralysis of the diaphragm were found. More than 50% of the patients showed a significantly restricted total and vital capacity. Most important was the fact that in 25% of the reexamined patients there existed an axial hernia of the hiatus caused by the trauma.

The diagnosis of diaphragmatic rupture following blunt trauma is difficult and often delayed. Introduced pneumoperitoneum can provide important diagnostic information. Its use is illustrated in a case of massive rupture of the right diaphragm where diagnostic pneumoperitoneum was valuable in distinguishing recent rupture from preexisting pathology.

Diaphragmatic rupture due to blunt trauma is rare in childhood. The possibility of such injury must be borne in mind whenever blunt abdominal and chest trauma is encountered. This paper reports a case of diaphragmatic rupture in a child with multiple injuries sustained in a road accident.

The diagnosis of acute diaphragmatic injury is difficult to establish in the immediate posttraumatic period. Patients with delayed diaphragmatic herniation frequently present months to years after the initial injury with manifestations of visceral incarceration, obstruction, ischemia from strangulation, or perforation. Patients with diaphragmatic herniation presenting with clinical tension pneumothorax are rare. We describe the case of a 23-year-old female who 16 weeks following a stab wound to the low chest presented with this clinical picture caused by herniation of abdominal viscera into the chest. A review of this entity and methods of discovery of delayed traumatic diaphragmatic herniation are described.

Three cases are presented of traumatic diaphragmatic hernia which represent different stages in the evolution of this pathology, illustrating the different clinical presentation, course, diagnostic methods and surgical solutions. Emphasis is placed on the importance of early diagnosis to reduce the mobi-mortality of this important disease. A bibliographic review is made.

As a result of modern investigative techniques surgeons now have fewer "blind dates with the abdomen". Nevertheless, the correct performance of a laparotomy remains an important diagnostic tool.

Rupture of the diaphragm and pericardium after blunt abdominal injury is a rare and serious lesion. This rupture can produce a secondary subacute or chronic cardiac tamponade due to herniation of the abdominal contents into the pericardial cavity. Diagnosis is difficult and therefore rarely mode early. Surgical repair can be made by thoracotomy or laparotomy.

A survey based on 122 personal observations of traumatic rupture of diaphragm, involving stomach and spleen herniation into the chest, is presented. The importance of clinical symptoms for proper diagnosis and treatment is discussed, in relation to the different trends in the literature.

Two patients had acute rupture of the diaphragm from blunt trauma. One was a nine-year-old girl with an associated fractured pelvis and intraperitoneal injuries. She required emergency repair through a laparotomy-thoracotomy. The second patient, a six-year-old boy, underwent repair of a diaphragmatic laceration, diagnosed after a latent interval. Thoracotomy was used.

Twenty-eight cases of diaphragmatic rupture due to blunt trauma are reviewed. The need for accurate and rapid diagnosis and results of treatment are discussed. Chest roentgenogram was found to be the best diagnostic aid. Surgical repair through an abdominal approach is advised in all acute cases. The high mortality rate in this series (28.6%) is related to the multiple injuries rather than to the diaphragmatic lesion itself.

A patient with gastric volvulus after traumatic diaphragmatic rupture is reported. The trias of Borchardt (pain in epigastrio with gastric distension, hiccups with the inability to vomit, inability to secure the passage of a nasogastric tube) must raise the suspicion on acute gastric volvulus, especially if these abdominal complaints are associated with blunt abdominal trauma in the past. In these cases, lateral X-ray examinations of the chest and swallowing studies establish the diagnosis.

The authors analyse a series of 10 patients urgently treated for traumatic disruption of the diaphragm. Main aetiopathogenetic, pathophysiological, diagnostic and surgical aspects of the condition are discussed.

Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. From 1957 to 1982, we treated 41 patients with traumatic diaphragmatic hernias. In 39 patients (95%), diaphragmatic hernia followed blunt trauma. The herniation occurred on the right side in 14 patients and on the left side in 29; it was bilateral in 2. Twenty-four patients had diagnostic chest radiographs, and an additional 11 had abnormal but nondiagnostic studies. Peritoneal lavage was of little value in making the preoperative diagnosis. Twenty-three patients underwent laparotomy only, 13 required thoracotomy alone, and 5 had combined laparotomy and thoracotomy. There were 7 deaths (17%) from associated injuries. Only one missed injury was encountered; a second delayed hernia, initially treated elsewhere, was repaired 45 years after the original trauma. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries. Right-sided injuries occur more commonly than previously thought and often require dual incisions (laparotomy and thoracotomy) for diagnosis and treatment. The organization of emergency care for such patients is critical in avoiding the potential of long-term sequelae.

Patients with traumatic rupture of the pericardium rarely survive to reach a hospital. Ten cases from the Maryland Institute for Emergency Medical Services Systems and 132 previously published cases are reviewed. Patients were usually men who were victims of violent thoracic trauma. The median age was 40 years. Half of the patients had left pleuropericardial tears; tears of the diaphragmatic pericardium, right pleuropericardium, and superior mediastinal pericardium were less frequent. Associated injuries of the heart or left hemidiaphragm were common. Pericardial rupture was usually discovered during surgical exploration for other indications, but physical or radiographic signs were occasionally present. Repair is indicated for most pericardial tears to prevent herniation of the heart or abdominal viscera.

Thirty-eight patients with acute diaphragmatic rupture secondary to blunt trauma have been reviewed. Peritoneal lavage is diagnostically inexact in patients with diaphragmatic rupture. One-fourth of the patients had falsely negative peritoneal lavages during their initial evaluation. All four patients without associated intra-abdominal injuries had falsely negative peritoneal lavages, as did four of 30 patients (13%) with significantly associated intra-abdominal injuries. We conclude from these data that: 1) peritoneal lavage is falsely negative in patients with isolated diaphragmatic rupture; 2) positive peritoneal lavage in patients with diaphragmatic rupture results from associated intra-abdominal injuries; and 3) peritoneal lavage may be falsely negative despite significant intra-abdominal injuries; because of herniation of injured organ(s) into the thoracic cavity, thus bleeding is excluded from the peritoneal cavity.