Acute Diaphragmatic Injuries Associated with Traumatic Rib Fractures: Experiences of a Major Trauma Centre and the Importance of Intra-Pleural Assessment

Abstract

Background Diaphragmatic injuries following blunt or penetrating thoraco-abdominal trauma are rare, but can be life-threatening. Rib fractures are the most common associated injury in patients with a traumatic diaphragmatic injury (TDI). We hypothesized that the pattern of rib fracture injuries could dictate the likelihood of acute TDIs. Methods A retrospective study was carried out between April 2014 and October 2018 to analyze patients with TDIs and rib fractures at a major trauma center in London, United Kingdom. Results Over the study period, 1,560 patients had rib fractures, of whom 14 had associated diaphragmatic injuries. Left-sided diaphragmatic injuries were found in 8 patients (57%) . A significant proportion of the rib fractures were located posterolaterally (44.9%). The highest frequency of fractures was found in ribs 5–10, which accounted for 74% of all the fractures. Ten patients underwent surgery, of whom 7 were diagnosed with a diaphragmatic injury intraoperatively after video-assisted thoracoscopic surgery assessment of the pleural cavity. Two patients died due to severe injuries of other organs and the remaining 2 patients were managed conservatively. Conclusion Our series of patients demonstrates a relationship between significant rib fractures and diaphragmatic injuries in trauma patients, and the diagnostic difficulties in identifying the condition. We found that the location of the rib fractures and the pattern of injury in patients with TDIs were much lower and posterolateral in the chest wall without a preference for laterality. We suggest using a thoracoscope in patients undergoing chest wall surgery post-trauma to aid in diagnosing this condition.

Surgery for Diaphragmatic Hernia Repair: A Longitudinal Single-Institutional Experience

“…In addition, access to posterior diaphragmatic defects is easily achieved through the thoracic approach. In our experience, concomitant bowel injury or strangulation could be repaired through an intrathoracic approach, which suggests that a suspicion of bowel ischemia does not preclude the thoracic approach [ 14 ]. Therefore, our findings suggest that in right-sided DH, regardless of the viability of herniated organs, the thoracic approach is the preferred method.…”

“…In this study, 33.3% of cases using the thoracic approach were performed by VATS. Since VATS has been widely adopted in the field of thoracic surgery, the repair of DH through VATS has been reported [ 14 - 19 ]. Accordingly, VATS became the preferred approach at our institution in 2017, regardless of the type of hernia.…”

Management of traumatic diaphragmatic injury—A peep into bowel repair via thoracotomy

“…Video thoracoscopy and video laparoscopy could contribute to the diagnosis and treatment of these lesions, with possibilities for a better postoperative period[ 10 24 25 ] and increased diagnostic yield, especially in patients with multiple rib fractures involving the lower chest wall. [ 24 26 ]…”