Diaphragmatic trauma: Difference between revisions
| (20 intermediate revisions by 6 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Associated with penetrating or blunt trauma to lower chest/upper abdomen | [[File:1113 The Diaphragm.jpg|thumb|Diaphragm anatomy from inferior view.]] | ||
[[File:Gray530.png|thumb|Left pleura cavity and diaphram (viewed from left).]] | |||
[[File:Body Cavities Frontal view labeled 2.jpg|thumb|The pericardial cavity in this image is labeled d and is part of the inferior mediastium. Here we can see its relation to the superior mediastinum a, the pleural cavities c, and the diaphragm e.]] | |||
*Associated with penetrating or blunt trauma to lower [[thoracic trauma|chest]]/[[abdominal trauma|upper abdomen]] | |||
**~65% from penetrating, 35% from blunt<ref>National Trauma Data Base. American College of Surgeons 2000-2004. https://ntdbdatacenter.com/ (Accessed on January 01, 2021).</ref> | |||
*If missed, can lead to herniation of viscera and tension enterothorax | *If missed, can lead to herniation of viscera and tension enterothorax | ||
*Most commonly left sided | *Most commonly left sided | ||
*Majority will have other injuries which can mask symptoms of diaphragm injury | *Majority will have other injuries which can mask symptoms of diaphragm injury | ||
*75% of the time occurs on the left side; the liver is protective on the right side | |||
*Presentation can be delayed months to years after the initial trauma | |||
==Clinical Features== | ==Clinical Features== | ||
* | *[[abdominal pain|Upper abdominal]]/[[chest pain|lower chest pain]] | ||
*Shortness of breath | *[[Shortness of breath]] | ||
*Diminished breath sounds on side of rupture | *Diminished breath sounds on side of rupture | ||
*Kehr Sign: shoulder pain from referred diaphragm pain | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Thoracic trauma DDX}} | {{Thoracic trauma DDX}} | ||
{{Abdominal trauma DDX}} | |||
==Evaluation== | ==Evaluation== | ||
*CXR may show visceral herniation | [[File:Diaphragmatic rupture spleen herniation.jpg|thumb|[[CXR]] of diaphragmatic rupture with spleen herniation.]] | ||
*CT chest/abdomen/pelvis with contrast may better detect smaller herniations ( | [[File:PMC5098930 poljradiol-81-522-g003.png|thumb|Coronal reformatted CT image shows constriction of the herniated stomach at the level of a ruptured diaphragm (collar sign) after blunt trauma.]] | ||
[[File:PMC5098930 poljradiol-81-522-g002.png|thumb|CT showing left hemidiaphragmatic rupture with a "dangling diaphragm | |||
sign and herniation of the stomach (confirmed on surgery).]] | |||
*[[CXR]] may show visceral herniation | |||
**Poorly sensitive | |||
*CT chest/abdomen/pelvis with contrast may better detect smaller herniations (roughly 82% sensitive and 88% specific) <ref> Yucel, M et al. Evaluation of diaphragm in penetrating left thoracoabdominal stab injuries: The role of multislice computed tomography. Injury. 2015 Sep;46(9):1734-7. </ref> | |||
**"Collar sign" | |||
***waist-like constriction of abdominal viscera | |||
*MRI better evaluates the diaphragm itself in stable patients in whom the diagnosis is unclear | *MRI better evaluates the diaphragm itself in stable patients in whom the diagnosis is unclear | ||
*Surgical exploration is ultimately the best diagnostic modality (thoracoscopy vs laparoscopy vs ex-lap depending on concurrent injuries) | *Surgical exploration is ultimately the best diagnostic modality (thoracoscopy vs laparoscopy vs ex-lap depending on concurrent injuries) | ||
*Thoracoscopy | |||
*Laparoscopy | |||
==Management== | ==Management== | ||
*[[NG tube]] decompression | |||
*Surgery is required to fix the defect | *Surgery is required to fix the defect | ||
Latest revision as of 22:10, 20 April 2022
Background
- Associated with penetrating or blunt trauma to lower chest/upper abdomen
- ~65% from penetrating, 35% from blunt[1]
- If missed, can lead to herniation of viscera and tension enterothorax
- Most commonly left sided
- Majority will have other injuries which can mask symptoms of diaphragm injury
- 75% of the time occurs on the left side; the liver is protective on the right side
- Presentation can be delayed months to years after the initial trauma
Clinical Features
- Upper abdominal/lower chest pain
- Shortness of breath
- Diminished breath sounds on side of rupture
- Kehr Sign: shoulder pain from referred diaphragm pain
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Abdominal Trauma
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Evaluation
CXR of diaphragmatic rupture with spleen herniation.
- CXR may show visceral herniation
- Poorly sensitive
- CT chest/abdomen/pelvis with contrast may better detect smaller herniations (roughly 82% sensitive and 88% specific) [2]
- "Collar sign"
- waist-like constriction of abdominal viscera
- "Collar sign"
- MRI better evaluates the diaphragm itself in stable patients in whom the diagnosis is unclear
- Surgical exploration is ultimately the best diagnostic modality (thoracoscopy vs laparoscopy vs ex-lap depending on concurrent injuries)
- Thoracoscopy
- Laparoscopy
Management
- NG tube decompression
- Surgery is required to fix the defect
Disposition
- Admit
See Also
References
- ↑ National Trauma Data Base. American College of Surgeons 2000-2004. https://ntdbdatacenter.com/ (Accessed on January 01, 2021).
- ↑ Yucel, M et al. Evaluation of diaphragm in penetrating left thoracoabdominal stab injuries: The role of multislice computed tomography. Injury. 2015 Sep;46(9):1734-7.