创伤性膈疝15例

Fifteen cases of traumatic diaphragmatic hernia

目的总结膈肌破裂和创伤性膈疝的临床表现及诊断治疗方法。方法对15例创伤性膈疝（左侧13例,右侧2例）患者的发病原因、合并伤、临床表现、诊断及治疗情况进行回顾性分析。结果本组15例均有2处以上合并损伤,其中多发肋骨骨折及血气胸9例,肺裂伤2例,胃破裂1例,骨盆骨折3例。第12胸椎椎体骨折伴截瘫1例,肝破裂2例,脾破裂1例,颅脑外伤2例,失血性休克5例。本组病例伤后确诊时间为24 h以内7例,24~72 h 7例,7 d 1例。12例术前已明确诊断,其中1例曾被误诊为张力性气胸,直到胸腔引流管引出食物残渣才得以诊断。3例在手术探查中发现。本组15例均经手术治疗后痊愈。结论单纯创伤性膈疝较少见,多有较严重的合并伤,表现缺乏特异性,易被伴发的胸腹部脏器损伤所掩盖,从而造成误诊或漏诊。详细了解受伤原因、部位及作用力方向,是早期诊断的关键。通过全面细致的体格检查、X线检查结合胸部CT、胃肠钡餐透视、B超等,可明确诊断。早期治疗应以抢救生命为重要原则,按照先重后轻的原则首先处理致命伤。膈疝一经确诊,无论裂口大小,均应及时手术。

Objective To summarise the clinical manifestations,diagnosis and therapeutic measures on traumatic diaphragmatic rupture and traumatic diaphragmatic hernia.Methods Retrospective analysis was made on 15 cases of traumatic diaphragmatic hernia,in which 13 cases occured on the left and 2 cases on the right.The reason of the disease,accompanying injuries,the clinical manifestations,diagnoses and therapy were analysed.Results In the group,each of all the patients had more than two accompanying injuries.Nine cases had multi-fractures of ribs and homothorax and pneumothorax,two cases had pulmonary rupture,one case had stomach rupture,three cases had pelvic fracture,one case had thoracic vertebral fracture and complete paraplegia,two cases had disruption of liver,one case had lienal rupture,two cases had head injury and five cases had hemorrhagic shock.After injury,definite diagnoses were made in 7 cases in 24 hours,7 cases in 24-72 hours,1 case in 7 days.Twelve cases of traumatic diaphragmatic hernia had been diagnosed surely before operations,among them 1 case had been misdiagnosed as tension pneumothorax until residue of food was found in the plearal cavity drainge.Three cases were found in operation.All the 15 cases were cured after surgical operation. Conclusion Pure traumatic diaphragmatic hernia happened rarely.In most occasions,there are severe accompanying injuries,so the clinical manifestations lacke characterastics,and wrong or delayed diagnoses are probably made.The key of diagnose early is understanding the injury reason and the location of injury and the direction of power.Correct diagnoses can be made by careful physical examination,X-ray and CT of chest,and barium meal.Saving life is the most important at the first stadge.Serious injury should be settled first.As soon as diaphragmatic hernia is diagnosed,surgical operation should be made promply.