Penetrating trauma to the junctional zone needs aggressive management

BMJ 2007; 334 doi: (Published 01 February 2007) Cite this as: BMJ 2007;334:257
  1. J Ahmad, specialist registrar, upper gastrointestinal surgery,
  2. G C Beattie, specialist registrar, upper gastrointestinal surgery,
  3. R Kennedy, specialist registrar, upper gastrointestinal surgery,
  4. J A Kennedy, consultant, upper gastrointestinal surgeon,
  5. W D B Clements, consultant, upper gastrointestinal surgeon
  1. 1Upper Gastrointestinal Unit, Royal Victoria Hospital, Belfast BT12 6BA
  1. Correspondence to: J Ahmad surgeonjawad{at}
  • Accepted 23 November 2006

Diagnostic laparoscopy or thoracoscopy can improve diagnosis of occult injuries to the diaphragm and reduce the risk of serious late morbidity

Stabbing injuries are now common, and the number of haemodynamically stable patients with penetrating injuries of the chest and upper abdomen who are treated conservatively has increased. The case we present supports a more aggressive approach to penetrating thoracic injuries that occur between the horizontal planes bounded by nipple line and umbilicus (junctional zone).

No universally accepted strategy for managing this condition exists. Some doctors use advanced cross sectional imaging1 complemented by clinical acumen; others adopt a more invasive approach—laparoscopy or thoracoscopy.2

We present a case where a missed injury to the diaphragm caused by penetrating thoracic trauma resulted in serious morbidity. We conclude that conservative management of such injuries results in a considerable risk of occult hernia of the diaphragm with potentially life threatening sequelae.


A 15 year old healthy boy was assaulted with a knife and sustained a penetrating injury to his left posterior chest wall at the level of the ninth rib. He was …

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