Original ResearchThe clinical implications of severe low rib fracture in the management of diaphragm injury: A Case Control Study

•Severe low rib fracture segments penetrate into the adjacent diaphragm sometimes.•Diaphragm injury caused by fractured rib may be undiscovered.•Low threshold for surgery should be considered in this undiscovered diaphragm injury.

BackgroundThe objective of this study was to analyze the differences in clinical presentation and characteristics with regard to diaphragmatic injury between blunt trauma patients with severe low rib fractures and those without severe low rib fractures.MethodsThe medical records of all patients with diaphragmatic injuries who were surgically treated at this level I trauma center, between January 2004 and December 2016 were reviewed. Patient notes, radiologic findings, and operative reports were evaluated. All of the diaphragmatic injuries were confirmed based on the operative findings. Rib fracture with displacement between the ends of the fracture of more than half the width of the fractured rib on computed tomography was classified as 'severe rib fracture'. Patients were categorized into 2 groups and analyzed: those who had more than one severe rib fracture in low ribs on the ipsilateral side of the diaphragm injury (Severe group), and those with no severe rib fracture (Non-severe group).ResultsDelayed diagnosis of diaphragmatic injury was more frequent in the Severe group than in the Non-severe group (81.8% vs 36.8%, p-value = 0.026). With regard to initial indications for operation, intrathoracic visceral herniation was more frequent in the Non-severe group (78.9% vs 18.2%, p-value = 0.002), while hemothorax was more frequent in the Severe group (63.6% vs 5.3%, p-value = 0.001). Central type diaphragmatic laceration was more frequent in the Non-severe group than in the Severe group (78.9% vs 18.2%, p-value = 0.002). The diameter of diaphragmatic injury was larger in the Non-severe group than in the Severe group (9.70 ± 4.10 cm vs 4.80 ± 3.60 cm, p-value = 0.004).ConclusionThe results of this study imply that a low threshold for thoracotomy or laparotomy should be considered in blunt trauma patients with severe low rib fractures for the purpose of hidden diaphragmatic injury detection and management.