Challenges in diagnosis and management of traumatic diaphragmatic injuries: experiences from a regional New Zealand trauma centre.

BACKGROUND: Diaphragmatic injury is a rare but serious consequence of thoraco-abdominal trauma, often overlooked due to its subtle initial presentation. Early recognition and surgical intervention of traumatic diaphragmatic injury (TDI) are paramount to treat life-threatening injuries, yet the diagnosis remains challenging due to the non-specific nature of symptoms and the limitations of conventional imaging techniques. This study aims to examine the burden of TDI among trauma patients of all injury severities presenting to the Level 1 trauma centre in New Zealand and evaluate the utility of pre-operative imaging in detecting patients who require operative repair of TDI. METHOD: A retrospective review of the Te Manawa Taki (TMT) Region's trauma registry from 2014 to 2023, with TDIs identified using Abbreviated Injury Scale diagnosis codes 440602, 440604, 440606, 440608, 440610 and 440699, was conducted. This is complemented by a review of clinical records of TDI patients admitted to the Level 1 trauma centre in the TMT Region to evaluate pre-operative imaging techniques used. RESULTS: The diagnosis of TDI was made pre-operatively in 29 of 43 patients (67.4%). The injury was visible on chest X-ray (CXR) in 19 patients (44%) and on computed tomography (CT) alone in 26 patients (81%). In 14 patients (32.5%) the diagnosis was only made intraoperatively. The detection rate of radiological imaging is significantly lower than intraoperative detection (rate ratios for CXR and CT are 0.44 and 0.81, respectively; p<0.05). CONCLUSION: TDI remains a rare and challenging diagnosis to establish solely through radiological imaging. Since TDI is often linked with other injuries, a low threshold for surgical intervention could be considered.