Penetrating Injury and the Diaphragm

It’s a Thursday night and all is calm in the trauma bay but then we get a call about a transfer of a patient who had been stabbed multiple times. So we abided our time until the patient arrived and a young woman arrives worried and anxious. She was jumped outside of a club and stabbed multiple times by an unknown person on the streets. She arrived to us and we examined her wounds. We obtained a CT for a back/flank stab wound, and it showed a grade 2 splenic laceration.  So due to the location of her injury we were concerned about possible diaphragm injury. The patient was thus taken to the OR for an exploratory laparoscopy which converted into an exploratory laporatomy after we were able to localize the injury. There was primary closure of the defect and the patient did well post-op and was discharged home with a follow up in clinic.

            Penetrating injuries to the thoracoabdominal region, such as stabs, gunshot, shotgun and impalements, account for about 65 percent of all diaphragmatic injuries. Penetrating injury is actually more common on the left as opposed to the right due to the fact that most people are right handed which was also the case for this patient. There is no gold standard for diagnosing diaphragm injuries however classically a CXR would be preformed. CT is the second study of choice (for posterior injuries) however it’s poor in detecting injuries due to artifact defects. Now minimally invasive procedures like laparoscopy and thoracoscopy are now the diagnostic and therapeutic choices in selected stable patients with penetrating injuries to the upper abdomen and lower chest. 

Overall when you have a patient come in with a penetrating thoracic injury you should keep in mind that there might be a possible diaphragmatic injury. In the case of this patient the location of her injuries led us to the clinical suspicion of this injury. IN addition her splenic laceration also helped us think of a possible injury to the diaphragm which led us to the OR.

http://www.uptodate.com/contents/recognition-and-management-of-diaphragmatic-injury-in-adults

http://ispub.com/IJS/30/1/1513

http://www.med.unc.edu/surgery/education/files/articles/Injuries%20to%20liver,%20biliary%20tree,%20spleen%20and%20diaphragm.pdf

by Angela P., medical student

Editor's Note - The information above refers to blunt diaphragmatic injuries which tend to be larger and more visible on CT scan.  

When looking for diaphragmatic injuries following penetrating trauma, we obtain a triple-contrast CT if the wound is posterior.  This is predominantly to look for retroperitoneal injuries, although occasionally suspicion will arise for a diaphragmatic injury as in this case.  For anterior thoracoabdominal stab wounds, a diagnostic peritoneal lavage remains the most sensitive test for ruling out diaphragmatic injuries.  This procedure is used primarily by centers that receive a lot of penetrating trauma, like ours.