Diaphragmatic trauma

Background

Diaphragm anatomy from inferior view.

Left pleura cavity and diaphram (viewed from left).

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 chest/upper abdomen
  • ~65% from penetrating, 35% from blunt
• 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
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Evaluation

CXR of diaphragmatic rupture with spleen herniation.

Coronal reformatted CT image shows constriction of the herniated stomach at the level of a ruptured diaphragm (collar sign) after blunt trauma.

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)
  • "Collar sign"
    • waist-like constriction of abdominal viscera
• 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

• Thoracic Trauma