About traumatic diaphragmatic hernias Incidence in the foothills of the Himalayas may be higher than the plains- relation to climbing trees for animal fodder or falls from roads in hills onto trees or slopes Every blunting of CP Angle in trauma pts must raise the possibility Varied clinical spectrum. Can be repaired by general surgeons themselves with good results Associated injuries often influence the eventual outcome

1. The Blunt C/P Angle in trauma
patients –
BEWARE!
Traumatic diaphragmatic hernias-A
common entity in hilly regions with
a varied presentation
Dr Alok Vardhan Mathur,
Dr Mohan Singh , Dr K. K. Sinha, Dr Madhukar Maletha, Dr J P Sharma, Dr Subhash Sharma,Dr Anurag Bijalwan
Shri Guru Ram Rai Insitute of Medical and Health Sciences,
Patel Nagar,
Dehradun, India
dralokvardhanmathur@yahoo.com

2. • (Figure55

3. • 35 year old male
• Abdominal pain, vomiting, fever
• On Examination- tachycardia, febrile, . Abdominal
tenderness, reduced air entry leftiu base
• Inv – leucocytosis, Blunting of Lt C/P angle, Mild free
fluid in Abdomen
• CT Abdomen-Diaphragmatic hernia with stomach and
bowel loops in chest
• Laparotomy –Diverticulitis with abscess with purulent
fluid in peritoneal cavity- peritoneal lavage .
Diaphragmatic hernia repaired in second stage

11. Traumatic diaphragmatic injury - really an indicator of severe injury ?
Dr Alok Vardhan Mathur, MS, Dr Manish Anand, DNB , Dr Madhukar Maletha, M Ch. (Ped Surg),
Prof (Brig) Ramesh Kumar, MS.
Department of Surgery, Shri Guru Ram Rai Institute of Medical and Health Sciences,
Patel Nagar, Dehradun 248001
Introduction Discussion
Background: Traumatic diaphragmatic injuries occur as a result of both blunt and •Look out for them, in the presence of haemo dynamic instability, with abdominal
penetrating Trauma . Optimal treatment consists of repair through an abdominal pain, intestinal obstruction, pneumo-pericarditis, tension feco-pneumothorax , even
approach with adequate attention to associated injuries. Most deaths in such with hematemeisis and malena .
patients are not the result of the diaphragmatic injury itself, instead they are often •More frequent in males with blunt high velocity trauma, and on the left side
related to the associated injuries. •X Ray signs: Collar sign, Diaphragmatic elevation, NG in thorax
CT signs : Injury visualized, intra thoracic herniation , contrast extravasation ,
Methods collar sign, intra thoracic displacement of liver and spleen with spleenic vein
thrombosis, large right diaphragmatic rupture with herniation of liver, gall bladder,
Case 1: A 35 year female, with high velocity RTA, poly trauma, head injury, lower
right kidney, ureter and renal vein
limb fractures, pelvic fracture ,on ventilatory support, is referred to surgery, CXR
•FAST scan : Reduced diaphragmatic movement on same side
and CT are shown below. On laparotomy, a 10 cm rent in diaphragm, with herniating
•A high index of suspicion, together with the knowledge of the mechanism of trauma,
viable stomach and bowel loops, is repaired, she makes an uneventful recovery -
is the key factor for the correct diagnosis[2].
GCS score improves only gradually -Discharged from neurosurgery about 35 days
• Incorrect interpretation of the x ray or only intermittent
later.
•hernial symptoms are frequent reasons for incorrect diagnosis[3]
•Right sided ruptures - high mortality and morbidity ,less likely than left sided tears
•Mortality rates of 5 to 50% (higher when strangulation of herniating loops)
• Meticulous per op examination of the diaphragm essential
•Upto 30% present late [1] (Cause: delayed rupture of a devitalised diaphragmatic
muscle, often precipitated by extubation)
Conclusions: A careful search for these injuries is warranted in poly trauma patients,
as up to 1.6% of these patients may have such injuries. They are commoner in males
Conclusions
and on the left side. Their presentation may be silent or related to the cardio
respiratory effects that they may cause. They should always be repaired to avoid
long term complications resulting from strangulation of herniating bowel loops.
Laparoscopy is being used increasingly to determine diaphragmatic integrity.
Patients with isolated diaphragmatic injuries tend to recover without long-term
disability
Case 2: 35 year old male - RTA victim – CXRPA shows blunt left CP Angle - ICD
drains bilious fluid –Laparotomy reveals 5cm tear in left diaphragm with small bowel
injury –diaphragm repaired with interrupted prolene sutures–post op develops
intrabdominal collection-discharged on POD 16 References
Case 3: 12 year old boy – 1. Pappas-Gogos G, Karfis E, Kakadellis J, Tsimoyiannis EC. Intrathoracic cancer of the
RTA victim with respiratory splenic flexure. Hernia. 2007;11:257–259. doi: 10.1007/s10029-006-0182-3. [PubMed]
distress and shock- CXR Results 2. Mintz Y, Easter DW, Izhar U, Edden Y, Talamini MA, Rivkind AI. Minimally invasive
shown , on laparotomy, procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct
viable stomach, spleen and diagnosis in selected patients. Am Surg. 2007;73:388–392. [PubMed
small bowel found in chest – 3. DeBlasio R, Maione P, Avallone U, Rossi M, Pigna F, Napolitano C. Late posttraumatic
diaphragmatic rent is repaired diaphragmatic hernia. A clinical case report. Minerva Chir. 1994;49:481–487.
with interrupted vicryl - [PubMed]
discharged on POD 8.
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12. • Blunt and penetrating trauma.
• They are often associated with significant associated injuries
• Recognized by fluid in the CP angle, lower lobe collapse, elevated
hemidiaphragm or by bowel loops in the chest.
• Up to 70% of cases may be missed on chest radiographs and they
may be associated with significant associated injuries which may by
themselves be fatal.
• CT scan and MRI may play and important role in diagnosis.
• Stress the need of a high index of suspicion.
• Optimal treatment consists of repair through an abdominal
approach with adequate attention to associated injuries.
• Most deaths in such patients are not the result of the
diaphragmatic injury instead they are related to the associated
injury.

13. Clinical presentation
 Respiratory distress
 Decrease breath sounds on affected side
 Palpation of abdominal contents on insertion of chest
tube or drainage of bowel contents in ICD
 Bowel sounds in chest
 Paradoxical abdominal movement on respiration
 Diffuse abdominal pain
 Hemodynamic or respiratory instability
 Intestinal obstruction
 Asymptomatic
 Low oxygen saturation

14. Associated injuries
• Polytrauma – head injuries, limb and pelvic
fractures.
• Bowel perforation
• Spinal trauma
• Other iatrogenic trauma
• Asymptomatic
• Interval from trauma to repair- 12 hours to 10
years, one patients never underwent surgery

15. Findings
• Left sided in all patients
• Small bowel, spleen, stomach, colon in chest
• Strangulated small bowel in one patient
• Head injury – cerebral contusions , spinal injury,
vertebral body fracture
• Suspected the hernia on the basis of CXRPA in all
our patients , confirmation on basis of CT Scan
• Surgery offered to all , one refused it.

16. Results
• Twelve cases
• Dehradun- tertiary care center
• Frequent after RTA, fall from height in hilly regions
• Sudden increase in intra-abdominal pressure following
a fall
• Countre coup injuries- to explain spinal and head
injuries
• By themselves they can be treated with good results.
• However the mortality and morbidity is often decided
by the nature of associated injuries.
• More in males, in high velocity injuries, left side

17. Surgery
• All repaired abdominally
• Mesh used in one
• Results of repair were good
• Three needed post op ventiatory support
• One pt- intraabdominal collection – treated
conservatively
• Associated injuries influenced the morbidity
hospital stay.

18.  A careful search for these injuries is warranted in polytrauma patients, and upto
1.6% of such patients may have such injuries.
 They are commoner in males
 On the left side(except in children where the rates are equal)
 Occur more frequently after blunt trauma especially after motor vehicle accidents.
 Their presentation may be silent or related to the cardiorespiratory effects that
they may cause.
 Some of them may be discovererd during laparotomy.
 They should always be repaired to avoid long term complications resulting from
strangulation of herniating bowel loops.
 Laparoscopy is being used increasingly to determine diaphragmatic integrity. The
outcome is generally related to concomitant injuries.
 Reported mortality ranges from 5.5-51%.
 People with isolated diaphragmatic injuries tend to recover without long-term
disability

19. Take home message
• Incidence in the foothills of the Himalayas may
be higher than the plains- relation to climbing
trees for animal fodder or falls from roads in hills
onto trees or slopes
• Every blunting of CP Angle in trauma pts must
raise the possibility
• Varied clinical spectrum.
• Can be repaired by general surgeons themselves
with good results
• Associated injuries often influence the eventual
outcome