The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years.

BACKGROUND: Our understanding of traumatic diaphragmatic injury (TDI) is based primarily on outdated retrospective series. We sought to reexamine present day patterns of diagnosis, associated injuries, predictors of mortality, and long-term outcomes of this condition.

METHODS: A prospectively entered trauma database from the Montréal General Hospital was reviewed for patients admitted with a TDI from 1993 to 2006. Hospital charts were reviewed, and patient characteristics, mechanism of injury, associated injuries, operative management, and postoperative outcomes were recorded. Logistic regression was used to identify predictors for mortality.

RESULTS: Identified were 105 patients with TDI consisting of blunt in 37% and penetrating in 63%. Only 23% of TDI were diagnosed on initial chest roentgenogram. External wounds in penetrating TDI cases were found in the abdomen alone in 19%, in the chest alone in 46%, and in both in 35%, which was associated with intraabdominal organ injury in 83%, 55%, and 87%, respectively. Less than half of patients had a diaphragmatic hernia. Lung, chest wall, and thoracic organ injuries were more common in blunt trauma, but there was no significant difference between abdominal injuries in both mechanisms. Overall mortality from TDI was 18%, and there was no difference between blunt and penetrating injury. In blunt trauma, brain injury and an Injury Severity Score (ISS) exceeding 15 were independently associated with increased death. In penetrating trauma, only an ISS exceeding 15 predicted death.

CONCLUSIONS: Traumatic diaphragmatic injury remains a challenge to diagnose and treat, primarily due to the presence of associated injuries. The high incidence of intraabdominal organ injury, irrespective of the site of penetrating wound, dictates a transabdominal approach for exploration and repair. Severity of associated injuries (ISS) predicts death.