Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes

Objective: Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. Methods: A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. Results: A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. Conclusion: The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.