Blunt diaphragmatic rupture in elderly patients.
OBJECTIVE
Severe blunt torso trauma can cause diaphragmatic rupture. Such trauma remains a diagnostic challenge to the trauma surgeon, particularly when the initial chest roentgenogram is unrevealing. Owing to age, preexisting diseases, and poor physiological reserves, elderly patients suffer higher mortality rates after trauma than young patients. The difference between elderly and young patients in terms of blunt diaphragmatic rupture is particularly interesting.


METHODS
Records from 78 patients presenting with blunt diaphragmatic rupture at our hospital from July 1992 to January 2001 were retrospectively reviewed. Age, gender, co-morbid disease, trauma mechanism, associated organ injury, injury severity score, hemodynamic status on arrival at our Emergency Room, injury side and size of diaphragmatic rupture, delay before operation, and postoperative complications and mortality were determined for elderly (> or = 65 years) and young (<65 years) patients.


RESULTS
10 elderly and 68 young patients were collected and reviewed. Elderly patients had higher rate of preexisting disease (60% vs. 16.2%), associated injury of long bone fracture (60% vs. 23%), and initial normal chest roentgenogram (50% vs. 12%) and they had significant delays before operation. Only 20% of elderly patients were operated on within 24 hours of trauma, compared to 87% of young patients, and 50% elderly patients were actually operated on over a week after the trauma. Furthermore, no statistically significant differences existed between elderly and young patients in ISS (19.9 +/- 6.3 & 22.8 +/- 10.4), or the injury side of diaphragmatic rupture, although elderly patients did display shorter diaphragmatic ruptures (5.6 +/- 3.3 & 10.0 +/- 6.0cm, p<0.05), and longer periods on postoperative ventilatory support (17.7 +/- 21.2 & 3.2 +/- 5.0 days, p<0.05). Finally, elderly patients also had significantly higher rates of postoperative complications of pneumonia (30% & 5.9%), and mortality (50% & 2.9%) than young patients did.


CONCLUSIONS
Compared to young patients, elderly patients with blunt diaphragmatic rupture had significantly higher rates of initial normal CXR, partly due to shorter length of diaphragmatic rupture, and partly due to ventilatory support, and consequent higher rate of delays before surgery. Furthermore, they also needed longer postoperative ventilator help, and prevailed higher rates of co-morbid disease, postoperative pneumonia, and mortality. Careful initial investigation and prudent radiological follow-up is recommended for elderly patients with severe blunt torso trauma.
Hsu
Yu-Pao
YP
Division of Trauma and Emergency Surgery, Surgical Department, Chang-Gung Memorial Hospital, Chang-Gung University, Taiwan, Republic of China. yupao@cgmh.org.tw
Chen
Ray-Jade
RJ
Fang
Jen-Feng
JF
Lin
Being-Chuan
BC
D000007:Abdominal Injuries / Q000175:diagnosis* / Q000453:epidemiology* / Q000601:surgery; D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D002648:Child; D002681:China / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006549:Hernia, Diaphragmatic, Traumatic / Q000453:epidemiology* / Q000209:etiology* / Q000601:surgery; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D017678:Sex Distribution; D018709:Statistics, Nonparametric; D014949:Wounds, Nonpenetrating / Q000150:complications* / Q000175:diagnosis / Q000601:surgery