|Year : 2013 | Volume
| Issue : 4 | Page : 256-261
Injury to the diaphragm: Our experience in Union Head quarters Hospital
Angeline Neetha Radjou1, Dillip Kumar Balliga2, Muthandavan Uthrapathy3, Ranabir Pal4, Preetam Mahajan5
1 Department of Surgery, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Director Department of Health and Family Welfare, Government of Puducherry, Puducherry, India
3 Department of surgery, Indira Gandhi Government General Hospital and Postgraduate Institute, Puducherry, India
4 Department of Community Medicine, All India Institute of Medical Sciences, Jodhpur-342005, Rajasthan, India
5 Department of community and family medicine, AIMS, Bhuvaneshwar, Orissa, India
|Date of Web Publication||2-Jan-2014|
Angeline Neetha Radjou
Department of Surgery, Indira Gandhi Medical College and Research Institute, Puducherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Diaphragmatic injury is a global diagnostic and therapeutic challenge. Objectives: The study was to identify the variations in the risk factors, diagnosis, management, and outcome between blunt and penetrating injuries of the diaphragm.
Materials and Methods: A prospective study was conducted on patients who were diagnosed with injury to diaphragm during preoperative, intraoperative, or postmortem period. The risk correlates and the trail of events following injury, interventions, and outcomes were studied.
Results: Of the 25 cases, blunt injury was experienced by 10. Road traffic injury was the most common cause in blunt trauma and assault with knife in penetrating trauma. Acute presentation was the most common mechanism. X-rays were positive in 52% cases. The most common reason for false negative X-rays was massive effusion/hemothorax. Computed tomography (CT) improved the positivity rate to 62.5%. A total of 25% of diaphragmatic injuries were diagnosed during surgery for hemodynamic instability irrespective of initial X-rays findings. Laprotomy alone was sufficient in majority of cases. The defects were largely in the left side; mean defect size was more in blunt trauma. Associated injuries were noted in 92%. Stomach was most affected in penetrating injuries and spleen in blunt trauma. Empeyma was the most common morbidity. Mortality rate of 13% in penetrating injury was far lower than 60% in blunt injury. Mean Injury Severity Score (ISS) was significantly related to the fatal outcomes irrespective of mechanism. Diagnostic laparoscopy for asymptomatic low velocity junctional penetrating wounds revealed diaphragmatic injury in 20%.
Conclusions: The incidence of multisystem injuries at our trauma center is on the rise. A high index of suspicion is needed for diagnosis of diaphragmatic injury. The need for thorough exploratory laprotomy is essential. In resource stretched setting like ours, the need for routine diagnostic laparoscopy in asymptomatic junctional wounds has to be validated further.
Keywords: Blunt trauma, diaphragmatic injury, penetrating trauma, viscerthorax
|How to cite this article:|
Radjou AN, Balliga DK, Uthrapathy M, Pal R, Mahajan P. Injury to the diaphragm: Our experience in Union Head quarters Hospital. Int J Crit Illn Inj Sci 2013;3:256-61
|How to cite this URL:|
Radjou AN, Balliga DK, Uthrapathy M, Pal R, Mahajan P. Injury to the diaphragm: Our experience in Union Head quarters Hospital. Int J Crit Illn Inj Sci [serial online] 2013 [cited 2022 Dec 7];3:256-61. Available from: https://www.ijciis.org/text.asp?2013/3/4/256/124139
| Introduction|| |
Traumatic diaphragmatic ruptures (TDR) result from blunt and penetrating injuries. In 1541 Sennertus was the first to document a case of diaphragm injury.  Various terms have been used to describe this event including diaphragmatic rupture, injury, and hernia. By definition, a traumatic diaphragmatic hernia is the incursion into the thorax of normally intraperitoneal structures after a traumatic event.  By virtue of its location between the chest and abdomen, the diaphragm is rarely injured in isolation in blunt trauma. Hence the signs and symptoms of acute trauma to the diaphragm may often be masked by severe concomitant injuries to other organs. Clinical presentations vary from asymptomatic, hemodynamic instability, and cardiac arrest to gastrointestinal obstruction and respiratory insufficiency. Temporal presentation can be within hours or even many years later. The involvement of two body cavities may cause problems in identifying the path of trajectory, deciding on the priority of intervention and limitation of contamination. Diagnosis is complicated by the lack of a single reliable imaging modality and the frequent presence of concomitant multi system injuries, which direct attention away from the diaphragm. Hence diaphragmatic injury remains a diagnostic and therapeutic challenge to trauma surgeons. A study was conducted on the variations in the profile of diaphragmatic injury to identify various risk factors, diagnosis, management, and outcome between blunt and penetrating injuries of the diaphragm.
| Materials and Methods|| |
This prospective study captured all the cases with confirmed diaphragmatic injuries admitted at the union territory headquarters tertiary care hospital in Puducherry over a period of 6 years from December 2005 to November 2011.
Prior to study commencement, the Medical Superintendent of the Indira Gandhi Government General Hospital, Puducherry and the Director of Medical Services Government of Puducherry granted permission to conduct this study.
Data collection techniques
The participants or their caregivers provided informed consent assuring them of participant protection. We included all confirmed traumatic diaphragmatic injury. A partially open ended semi structured case study format was used to note down the socio-demographic characteristics of the patients to determine the mechanisms of injury, risk factors, prehospital times, associated injuries, interventions, and postoperative outcome variables. The Injury Severity Score (ISS) was recorded in each individual case. Postmortem was done in all cases of death. Patients were resuscitated according to standard trauma protocols with chest X-rays in the primary survey. Computed tomography (CT) scan/laparotomy were the next management option depending on the clinical condition, and the chronological mode of presentation. We categorized patients into acute, latent, and chronic phases according to the temporal presentation. Acute: When the diaphragmatic injury was diagnosed in the initial phase of trauma care, usually up to a week. Intermediate: When the diaphragmatic injury manifested/diagnosed, after the acute injuries had resolved in about 30 days. Chronic: When a diaphragmatic hernia was confirmed on imaging but the significant trauma had occurred years earlier.  ISS was determined by the intraoperative findings or at postmortem when death occurred before diagnosis and/or intervention. Organ injury scoring for the diaphragm and associated injury was done as described by Moore. 
The collected data was analyzed using means and proportions, data were represented as figures wherever appropriate.
| Results|| |
TDR was identified in 25 patients out of 2204 patients admitted with significant abdominal-thoracic trauma, which constitutes less than 1% of the total trauma cohort. A total of 40% had blunt trauma while 60% had penetrating trauma. Road traffic accident and fall from height (80%) was the most common cause in blunt trauma and assault with knife (73%) was the most common cause in penetrating trauma. The male to female ratio was 21:4. Acute presentation was the most common in blunt (60%) as well as penetrating trauma (87%). The mean prehospital time was 335 min in blunt group and 139 min in the penetrating group.
Plain X-rays was positive in 52%. Massive effusion was the most common cause for negative X-rays. A noteworthy proportion of patients (48%) were taken to laparotomy without further imaging/equivocal imaging due to hemodynamic instability at presentation or deterioration in clinical conditions. Two cases that were CT negative were confirmed only at postmortem.
Associated injuries were noted in 23 cases; being more common in blunt trauma (100%) than the in penetrating trauma (86%). Extra-abdominal injuries other than lung were noted only in blunt trauma. Stomach was the most common associated organ injured in penetrating injury (33%) and spleen in blunt trauma (30%) [Table 1]. A total of 90% of the defects were in the left side of the diaphragm. Of the 23 cases of surgical interventions, laparotomy alone was sufficient in 65.5% for a primary repair and to manage the associated injuries. Mean defect size was less in penetrating injuries (1.94 cm) compared with blunt (5.09 cm) trauma and all were amenable to a tension free primary repair. Postoperative complications were noted in 53% of the penetrating and 20% of blunt trauma. Prolonged emphyema (20%) was the most common complication [Table 2]. Mortality was 60% in the blunt and 13% in the penetrating group. Mean ISS > 25 was significantly related to the fatal outcome (P = 0.0230) [Table 3]. The diaphragmatic injury in all our patients had ISS score of 9. It was the severity of associated injuries that added up to the mortality when scores were 25 and above [Figure 1]. One single death of ISS 18 was attributed to direct result of diaphragmatic injury.
| Discussion|| |
The incidence of TDR of 0.9% in our study participants was similar to 0.8-5% as noted by Rossetti et al. The diaphragmatic injuries affected predominantly males (male: female 21:4), mean age of 34.05 (range 22-60). The blunt to penetrating incidence of 2:3 is in contrast to 13:7 in the study by Lopez.  Fluctuation in prevalence probably reflects the difference in the incidence of interpersonal violence.
There was a marked difference in the mean prehospital time of 335 min in blunt and 139 min in the penetrating group. To the best of our efforts we could not find other studies to compare this aspect. This difference in mean time may be explained by the fact that penetrating injury had localized overt bleeding with no associated multiple injuries, which would preclude dependence on special vehicles to transport to trauma facility. Additionally, most assault cases occurred in urban environments, thereby reducing the time to hospital admission.
All patients had X-rays chest in the primary survey. The X-rays positivity for blunt group was 48% higher than 23% reported by Hanna  and far lower than 73% by Sliker  Diaphragmatic injury could be masked in collapse, pneumothorax, hemothorax, or pulmonary contusions that are frequently seen in trauma patients independent of injury to diaphragm.  Diagnostic sensitivity can also be increased by repeating the chest X-rays after 6 hours.  Associated herniation of the contents into the thorax raises the accuracy to 90% but herniation of abdominal contents through a diaphragmatic injury occurs in less than 50% of injuries.  Visualization of nasogastric tube in the intrathoracic stomach is almost a confirmatory sign.  Helical CT was positive in 66.7% for blunt injuries but only 33.33% for the penetrating group. Multislice CT study has shown that detection of diaphragmatic injury had sensitivity of 71-100% and specificity of 75-100%.  Repeated imaging including CT was negative for diaphragmatic injury in a ventilated head injured patient, which could be diagnosed only on postmortem similar to report by Pantelis et al. Intrapleural-contrast CT scan  and M - mode ultra sonography (USG)  have been promising.HYPERLINK "/article/S0020-1383 (10) 00773-4/abstra. Magnetic resonance imaging, although accurate, is not practical in the emergency setting, limiting its applicability to the assessment of chronic diaphragmatic herniation. 
The incidence of R: L side defect in our study was 4:21. This observation is comparable to a study from India.  The left hemi diaphragm is congenitally weaker at its points of embryonic fusion, and hence easily injured.  The size of defect was a mean of 5.09 cm in blunt 1.94 cm in the penetrating group. The defect is larger in blunt injuries as major energy transfer is involved. 
Laprotomy was sufficient in 80% of our cases for a primary repair and to tackle the often associated injuries, which are similar to findings by Hanna et al. Even the single case of chronic hernia was successfully repaired through the laprotomy route. There are concerns that in more chronic presentations, there may be incarceration of abdominal contents with adhesions and reduction through the abdomen would be unwise. In these situations if preoperative imaging confirms that the hernia is above the inferior pulmonary vein a thoracotomy may be safer.  we used thoracic approach in two patients with injury on R side. Thoracotomy was sufficient to primarily close the diaphragmatic injury in one patient. Video-assisted thoracoscopy to remove a sharp foreign body from R pleural cavity was done. The small diaphragmatic rent of 0.05 cm was not attempted to repair as the liver was densely adherent to the defect. Many cases of right side injury can be managed without surgery as the risk of liver herniation is low , and animal studies have suggested that small defects would heal on their own.  All defects could be primarily closed without tension[Figure 2]. The cardinal surgical principles are reduction of the hernia and water tight closure to prevent recurrence. Large defects may need a mesh for a tension free repair and in chronic defects with no incarceration.  However, it is better to avoid mesh in the acute setting as the high rate of associated intestinal injury would lead to infection. The choice of suture material is nonabsorbable for a water tight closure as absorbable sutures lead to higher rate of recurrence.
100% of blunt and 80% of penetrating injury had an associated serious injury, which is similar to the study by Duzan et al. Associated injuries were mainly intraabdominal, although there were a significant proportion of extra abdominal injuries in the blunt group. Stomach (33%) was the most frequent organ involved followed by the spleen (30%) and intestine (8%). The stomach was injured in 50% as reported by Hanna.  One patient had associated aortic injury, an association reported earlier. 
The mortality was 60% in blunt and 13% in penetrating injuries. Reported mortality rates vary between 18% and 40%, depending on whether the mechanism of trauma is blunt or penetrating.  However, Hanna reported no difference in mortality rates between the groups.  The diaphragmatic injury in all our patients had ISS score of 9. It was the severity of associated injuries regardless of the mechanism or defect size that increased the mortality when scores were 25 and above, confirming to the finding by Hanna  and Celik.  The lesser mortality (13%) in penetrating injuries in our studies was due lower mean ISS of 18.3 compared with 23.5 in blunt trauma with mortality rate of 60%. The mortality of 13% in penetrating injury is far less than 37.7%, in the Indian study due to high velocity missiles,  unlike the low velocity knife stabs in our study. One patient was severely hypoxemic due to tension viscerothora [Figure 3], which improved only after operative reduction of the hernia, but succumbed to the sequel of anoxic brain damage. There is only one other instance where the diaphragmatic injury was the immediate cause of death.  Respiratory distress due diaphragmatic hernias should be treated with intubation. An intercostal tube drainage is unlikely to help and may even lead to iatrogenic injuries.  Bleeding (3 cases) due to associated injuries was the main physiological impairment that tilted the outcome toward mortality [Table 3]. Hypovolemia was the leading cause (50%) of death in the study from India.  Hence prompt control of bleeding from associated injuries is paramount to survival. 
Diaphragmatic injury was missed in one case during laprotomy for perforation of the jejunum. Patient had a latent presentation with positive X-rays and CT. 5%of blunt trauma patients who undergo laparotomy have a diaphragmatic injury.  This calls for emphasis on thorough exploratory laprotomy in trauma without being reassured that the obvious problem is solved. Both domes of diaphragm need to be visualized and palpated as stressed by Sirbu et al. One missed diaphragmatic hernia had presented in latent phase following Non Operative management (NOM) for blunt splenic contusion. Missed diaphragmatic injury is rare but possible in 0.37% NOM of blunt injuries. This rare possibility should not interfere with eligibility criteria for NOM in blunt injuries.  We are managing more patients by NOM in our hospital now, which could lead to higher incidence of chronic presentations in the future, a legitimate concern already voiced out earlier. 
Our center has started routine laparoscopy for asymptomatic thoracoabdominal zonal injury. A total of 10% had diaphragmatic injury in contrast to 6% reported by Ahmed.  Hence the need for more liberal criteria for laparoscopy in this group to detect occult injuries to diaphragm.
The single case of chronic hernia underwent repair and survived. Another patient with chronic hernia with gastric gangrene died postoperative. The mortality from elective repair of chronic hernia is low. But the mortality rises up to 80% if there is bowel ischemia secondary to incarceration in the defect.  One hypothesis regarding the chronic presentation is that the diaphragm is only contused or devitalized in the first trauma with anatomical continuity. Subsequently there is rupture with loss of integrity and herniation of intraabdominal contents. 
Morbidity was present in 43% of operated patients. The most common complication was emphyema (13%) in the penetrating group associated with bowel injury in spite of thorough pleural toilet. The mandatory need to irrigate the chest cavity thoroughly during repair has to reemphasize as emphyema is three times as prevalent when there is documented bowel injury. , Out of the 15 patients who survived surgery, only 12 patients could be followed up. None of these patients had any sequel after diaphragmatic repair in the mean follow up period of 1.6 years. The patient with the 0.5 cm (R) side tear that was not sutured is well and on regular follow-up for the past 3 years.
Strength of the study
This study was undertaken on a rare injury highlighting preoperative diagnostic difficulty. The morbidity and mortality summary is highlighted. This may enable further study into areas that can be rectified.
Limitations of the study
This is a single center study with a small cohort, making the statistical validity poor. By this effort we have only outlined the problem of diaphragmatic trauma in our service area.
Future directions of study
This study is a pilot project to focus on the management of diaphragmatic trauma during the acute and resuscitative phase of trauma. It can be a stimulus to inspire dedicated trauma professionals to help in systematic organization of available facilities, and to upgrade facilities for a better response to diaphragmatic injury.
To conclude, diaphragmatic injury is a rare diagnosis, often delayed as imaging studies are not always helpful. Diaphragmatic injury is rarely the underlying cause of early trauma death in most cases, but the surgeon needs to have a high degree of suspicion to prevent the mortality associated with its long-term sequel.
| References|| |
|1.||Reid J. Case of diaphragmatic hernia produced by a penetrating wound. Edinburgh Med Surg J 1840;53:104. |
|2.||Blitz M, Louie BE. Chronic traumatic diaphragmatic hernia. Thorac Surg Clin 2009;19:491-500. |
|3.||Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg 1974;128:175-81. |
|4.||Moore EE, Malangoni MA, Cogbill TH, Shackford SR, Champion HR, Jurkovich GJ, et al. Organ injury scaling IV: Thoracic vascular, lung, cardiac and diaphragm. J Trauma 1994;36:299-300. |
|5.||Rossetti G, Brusciano L, Maffetone V, Napolitano V, Sciaudone G, DelGenio G, et al. Giant right post-traumatic diaphragmatic hernia: Laparoscopic repair without a mesh. Chir Ital 2005;57:243-6. |
|6.||Lopez PP, Arango J, Gallup TM, Cohn SM, Myers J, Corneille M, et al. Diaphragmatic injuries: What has changed over a 20-year period? Am Surg 2010;76:512-6. |
|7.||Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic Diaphragmatic injury: Lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008;85:1044-8. |
|8.||Sliker CW. Imaging of diaphragm injuries. Radiol Clin North Am 2006;44:199-211. |
|9.||Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: A diagnostic challenge? Radiographics 2002;22:S103-16. |
|10.||Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 2004;22:601-4. |
|11.||Goh BK, Wong AS, Tay KH, Hoe MN. Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma. CJEM 2004;6:277-80. |
|12.||Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR, Gotway CA, et al. Helical CT with sagittal and coronal reconstructions: Accuracy for detection of diaphragmatic injury. Am J Roentgenol 2002;179:451-7. |
|13.||Pantelis D, Burger C, Hirner A, Wolff M. Trauma mechanism and diagnosis of blunt diaphragmatic rupture. Chirurg 2006;77:360-6. |
|14.||Abbasy HR, Panahi F, Sefidbakht S, Akrami M, Paydar S, Mirhashemi S, et al. Evaluation of intrapleural contrast-enhanced abdominal pelvic CT-scan in detecting diaphragm injury in stable patients with thoraco-abdominal stab wound: A preliminary study. Injury 2012;43:1466-9. |
|15.||Gangahar R, Doshi D. FAST scan in the diagnosis ofacute diaphragmatic rupture. Am J Emerg Med 2010;28:387. |
|16.||Eren S, Fahri C. Diaphragmatic hernia: Diagnostic approaches with review of the literature. Eur J Radiol 2005;54:448-59. |
|17.||Lone RA, Akbar BM, Sharma M, Lateef WM, Ahangar AG, Lone G, et al. Missile Diaphragmatic injuries: Kashmir experience. Int J Health Sci (Qassim) 2009;3:19-21. |
|18.||Maish MS. The diaphragm. Surg Clin North Am 2010;90:955-68. |
|19.||Davis J, Eghbalieh B. Injury to the diaphragm. Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6 th ed. New York: McGraw-Hill; 2008. p. 623-35. |
|20.||Shatney CH, Sensaki K, Morgan L. The natural history of stab wounds of the diaphragm: Implications for a new management scheme for patients with penetrating thoracoabdominal trauma. Am Surg 2003;69:508-13. |
|21.||Hanna WC, Ferri LE. Acute traumatic diaphragmatic injury. Thorac Surg Clin 2009;19:485-9. |
|22.||Düzgün AP, Ozmen MM, Saylam B, Coºkun F. Factors influencing mortality in traumatic ruptures of diaphragm. Ulus Travma Acil Cerrahi Derg 2008;14:132-8. |
|23.||Shah R, Sabaratnam S, Mearns AJ, Choudry AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444-9. |
|24.||Celik A, Altinli E, Köksal N, Caðlayan K, Uzun MA, Erdoðan D, et al . Diagnostic process and management of diaphragmatic injuries: Approach in patients with blunt and penetrating trauma. Ulus Travma Acil Cerrahi Derg 2010;16:339-43. |
|25.||Beauchamp G, Khalfallah A, Girard R, Dube S, Laurendeau F, Legros G. Blunt diaphragmatic rupture. Am J Surg 1984;148:292-5. |
|26.||Matsevych OY. Blunt diaphragmatic rupture: Four year′s experience. Hernia 2008;12:73-8. |
|27.||Williams M, Carlin AM, Tyburski JG, Blocksom JM, Harvey EH, Steffes CP, et al. Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries. Am Surg 2004;70:157-62. |
|28.||Esme H, Solak O, Sahin DA, Sezer M. Blunt and penetratingtraumatic ruptures of the diaphragm. Thorac Cardiovasc Surg 2006;54:324-7. |
|29.||Sirbu H, Busch T, Spillner J, Schachtrupp A, Autschbach R. Late bilateral diaphragmatic rupture: Challenging diagnostic and surgical repair. Hernia 2005;9:90-2. |
|30.||Miller PR, Croce MA, Bee TK, Malhotra AK, Fabian TC. Associated injuries in blunt solid organ trauma: Implications for missed injury in nonoperative management. J Trauma 2002;53:238-42. |
|31.||Ahmed N, Whelan J, Brownlee J, Chari V, Chung R. The contribution of laparoscopy in evaluation of penetrating abdominal wounds. J Am Coll Surg 2005;201:213-6. |
|32.||Pross M, Manger T, Mirow L, Wolff S, Lippert H. Laparoscopic management of a late-diagnosed major diaphragmatic rupture. J Laparoendosc Adv Surg Tech A 2000;10:111-4. |
|33.||Eren S, Esme H, Sehitogullari A, Durkan A. The risk factors and management of posttraumatic empyema in trauma patients. Injury 2008;39:44-9. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||A rare case report of perforated viscerothorax in a traumatic diaphragmatic rupture
| ||Dennis Machaku, Marianne Gnanamuttupulle, Elizabeth Wampembe, Kondo Chilonga |
| ||International Journal of Surgery Case Reports. 2022; 99: 107688 |
|[Pubmed] | [DOI]|
||Conventional and minimally invasive surgery in diagnosis and treatment of thoracoabdominal wounds
| ||D. G. Amarantov,M. F. Zarivchatskiy,A. A. Kholodar,I. A. Balandina,A. S. Nagaev,E. P. Kainova |
| ||Khirurgiya. Zhurnal im. N.I. Pirogova. 2019; (6): 65 |
|[Pubmed] | [DOI]|
||Regarding operative treatment of thoracoabdominal injuries
| ||Dmitriy G. Amarantov,Mikhail F. Zarivchatsky,Andrey A. Kholodar,Andrey S. Nagaev,Oleg S. Gudkov |
| ||Perm Medical Journal. 2019; 36(1): 14 |
|[Pubmed] | [DOI]|
||Modern approaches to surgical treatment of thoraco-abdominal wounds
| ||D. G. Amarantov,M. F. Zarivchatskii,A. A. Kholodar,O. S. Gudkov,E. V. Kolyshova |
| ||VESTNIK KHIRURGII IMENI I.I.GREKOVA. 2018; 177(5): 100 |
|[Pubmed] | [DOI]|
||Descriptive Analysis of Right and Left-sided Traumatic Diaphragmatic Injuries; Case Series from a Single Institution
| ||Hassan Al-Thani,Gaby Jabbour,Ayman El-Menyar,Husham Abdulrahman,Ruben Peralta,Ahmad Zarour |
| ||Bulletin of Emergency and Trauma. 2018; 6(1 JAN): 16 |
|[Pubmed] | [DOI]|
||The clinical implications of severe low rib fracture in the management of diaphragm injury
| ||Seongyup Kim,Woo Jin Choi,Kawng Ho Lee,Chun Sung Byun,Keum Seok Bae,Il Hwan Park |
| ||International Journal of Surgery. 2017; |
|[Pubmed] | [DOI]|