Zwerchfellverletzungen – Klassifikation, Diagnostik und Therapie

Abstract

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.

Delayed Diagnosis of a Right-Sided Traumatic Diaphragmatic Rupture

“…In larger scales of patients, isolated injury occurs in roughly 50% of all cases of injured children, 4 and in 20% off all cases of injured adults. 5 The difference is caused by higher elasticity in childrens tissue. The injury is diagnosed more in boys than girls, largely due to the fact, that boys have a higher incident rate than girls.…”

Experimental investigation of the elasticity of the human diaphragm

“…The result is an acute increase in intraabdominal pressure exerting its forces on a reflectively contracted diaphragm. When the pressure rises to a certain value the elastic limit is reached and this causes the indirect diaphragmatic rupture [1]. …”

“…Since an acute increase in intraabdominal pressure is the main cause of diaphragmatic rupture [1,2] the defect manifests itself rather within the tendon or at the junction zone. Due to this type of force in clinical practice the increased tendency of tearing at the rib insertion in our experimental setting with tearing rather than pressure force being exerted would therefore in real life be less likely.…”

“…They appear predominantly on the left side [1,2]. A hypothesis for this phenomenon is seen in the protected position of the right diaphragm above the liver.…”

Indirekte traumatische Zwerchfellruptur

“…Heute stellen "Rasanztraumata" des modernen Straßenverkehrs die häufigste Ursache dar [23]. Durch die stumpfe Gewalteinwirkung auf Thorax, Abdomen und Becken kommt es zu einer Druckerhöhung im Bereich des Diaphragmas, die bei Überschreitung der Elastizitätsgrenze zu einer Berstungsruptur, meist am Übergang vom muskulären zum sehnigen Anteil, führt [23]. Die sofortige Diagnose einer ZR ist nicht immer einfach, insbesondere, wenn die initiale Thoraxröntgenaufnahme unauffäl-lig und eine Thorakotomie bzw.…”