Experience with acute diaphragmatic trauma and multiple rib fractures using routine thoracoscopy.

BACKGROUND: Diaphragmatic injury is mostly caused by blunt or penetrating traumas. It is an uncommon diagnosis and therefore carries the risk of being misdiagnosed or delayed in diagnosis. In our institution, we perform routine thoracoscopy for the management of patients with traumatic rib fractures. We have noted several cases of occult diaphragmatic injuries and hypothesize that these injuries may be more of a penetrating injury from rib fractures as opposed to the high velocity blunt trauma typically associated with diaphragmatic injuries.

METHODS: A retrospective review of medical records was performed on all patients admitted to our facility with rib fractures and traumatic diaphragmatic injuries. We looked at our trauma experience between January 2015 and January 2018.

RESULTS: Twenty-three patients with traumatic diaphragmatic injuries were found. Twenty-one of the diaphragmatic injuries were from blunt trauma. A total of 15 had associated rib fractures. Six of the blunt traumatic diaphragm injuries did not have rib fractures but had evidence of intra-abdominal injuries. The rib fracture pattern in the diaphragmatic injury group consistently involved rib fractures at or below the fifth rib.

CONCLUSIONS: We conclude that thoracoscopy may prove to be helpful in the algorithm for the work up of an occult diaphragmatic injury. The diagnostic yield appears to be greatest in patients with multiple rib fractures involving the lower chest wall even in the absence of intra-abdominal injuries or radiographic evidence of diaphragmatic abnormalities.