Recognition and management of diaphragmatic injury in adults
- Mallory Williams, MD, MPH, FACS
Mallory Williams, MD, MPH, FACS
- Professor of Surgery
- Howard University College of Medicine
Diaphragmatic injury is uncommon, representing less than 1 percent of all traumatic injuries [1,2]. The diaphragm is usually injured in association with other thoracic and abdominal organs. Although diaphragmatic injury can be obvious (eg, herniation of abdominal contents on chest radiograph), the injury may be subtle and imaging studies can be nondiagnostic. A high index of suspicion needs to be maintained because delayed diagnosis is associated with an increased risk for herniation and strangulation of abdominal organs, which can be life-threatening. For patients in whom the diagnosis is uncertain, diagnostic laparoscopy, thoracoscopy or open surgical exploration may be needed to establish the diagnosis. When identified, diaphragm injury is repaired with open surgical or minimally invasive techniques, the choice and timing of which depends upon the presence of associated injuries and the overall condition of the patient.
This topic will discuss the recognition and surgical management of blunt and penetrating injury to the diaphragm. Injuries to associated thoracic and abdominal organs are discussed in separate topic reviews. The general approach to blunt and penetrating chest and abdominal trauma are also discussed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Initial evaluation and management of blunt abdominal trauma in adults".)
ANATOMY OF THE DIAPHRAGM
The diaphragm (dia: across, phragm: fence) is the musculotendinous boundary between the negative-pressure thoracic cavity and positive-pressure abdominal cavity. The diaphragm plays a significant role in respiratory mechanics and injury to the diaphragm impairs ventilation and oxygen delivery. The normal mechanics of respiration are discussed elsewhere. (See "Diseases of the chest wall", section on 'Normal structure and function'.)
The diaphragm is dome-shaped and attaches to the chest and abdominal walls circumferentially (figure 1). The liver, spleen, transverse colon, stomach, pancreas, adrenal glands, and kidneys contact the undersurface of the diaphragm. Thoracoabdominal structures, including the aorta, inferior vena cava, thoracic duct, esophagus, vagus nerves and phrenic nerves, traverse the diaphragm through three major apertures (ie, aortic, caval, esophageal) (figure 2).
The diaphragm is composed of two muscle groups, costal and crural, which are compositionally and functionally distinct. Both groups are innervated by the phrenic nerves (figure 3 and figure 4). The costal muscle group that forms the diaphragmatic leaflets is thin, and contraction of its fibers flattens the diaphragm and lowers the ribs. The crural muscle groups are thicker but contribute minimally to the displacement of the diaphragm. The median arcuate ligament anterior to the aortic hiatus is formed by the continuation of the medial tendinous margins of the crura.
- Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EF (Eds), McGraw-Hill, 2008..
- National Trauma Data Base. American College of Surgeons 2000-2004. https://ntdbdatacenter.com/ (Accessed on January 01, 2005).
- Young RL, Page AJ, Cooper NJ, et al. Sensory and motor innervation of the crural diaphragm by the vagus nerves. Gastroenterology 2010; 138:1091.
- Fair KA, Gordon NT, Barbosa RR, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg 2015; 209:864.
- Hedblom, CA. Diaphragmatic hernia: A study of three hundred and seventy eight cases in which operation was performed. JAMA 1925; 85:947.
- Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma 1986; 26:438.
- Demetriades D, Kakoyiannis S, Parekh D, Hatzitheofilou C. Penetrating injuries of the diaphragm. Br J Surg 1988; 75:824.
- Wiencek RG Jr, Wilson RF, Steiger Z. Acute injuries of the diaphragm. An analysis of 165 cases. J Thorac Cardiovasc Surg 1986; 92:989.
- Williams M, Carlin AM, Tyburski JG, et al. Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries. Am Surg 2004; 70:157.
- Bergin D, Ennis R, Keogh C, et al. The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol 2001; 177:1137.
- May AK, Moore MM. Diagnosis of blunt rupture of the right hemidiaphragm by technetium scan. Am Surg 1999; 65:761.
- Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging of diaphragmatic injuries. J Thorac Imaging 2000; 15:104.
- Feliciano DV, Cruse PA, Mattox KL, et al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988; 28:1135.
- Bhavnagri SJ, Mohammed TL. When and how to image a suspected broken rib. Cleve Clin J Med 2009; 76:309.
- Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 2004; 22:601.
- Kim HH, Shin YR, Kim KJ, et al. Blunt traumatic rupture of the diaphragm: sonographic diagnosis. J Ultrasound Med 1997; 16:593.
- Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture. Am J Emerg Med 2010; 28:387.e1.
- Stein DM, York GB, Boswell S, et al. Accuracy of computed tomography (CT) scan in the detection of penetrating diaphragm injury. J Trauma 2007; 63:538.
- Bodanapally UK, Shanmuganathan K, Mirvis SE, et al. MDCT diagnosis of penetrating diaphragm injury. Eur Radiol 2009; 19:1875.
- Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002; 22 Spec No:S103.
- Bansal V, Reid CM, Fortlage D, et al. Determining injuries from posterior and flank stab wounds using computed tomography tractography. Am Surg 2014; 80:403.
- Ertan T, Sevim Y, Sarigoz T, et al. Benefits of CT tractography in evaluation of anterior abdominal stab wounds. Am J Emerg Med 2015; 33:1188.
- Shanmuganathan K, Mirvis SE, White CS, Pomerantz SM. MR imaging evaluation of hemidiaphragms in acute blunt trauma: experience with 16 patients. AJR Am J Roentgenol 1996; 167:397.
- Soyka JM, Martin M, Sloan EP, et al. Diagnostic peritoneal lavage: is an isolated WBC count greater than or equal to 500/mm3 predictive of intra-abdominal injury requiring celiotomy in blunt trauma patients? J Trauma 1990; 30:874.
- Gonzalez RP, Turk B, Falimirski ME, Holevar MR. Abdominal stab wounds: diagnostic peritoneal lavage criteria for emergency room discharge. J Trauma 2001; 51:939.
- Kamiyoshihara M, Ibe T, Takeyoshi I. Chilaiditi's sign mimicking a traumatic diaphragmatic hernia. Ann Thorac Surg 2009; 87:959.
- Payne JH Jr, Yellin AE. Traumatic diaphragmatic hernia. Arch Surg 1982; 117:18.
- Chen JC, Wilson SE. Diaphragmatic injuries: recognition and management in sixty-two patients. Am Surg 1991; 57:810.
- Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Occult marker of serious injury. Ann Surg 1993; 218:783.
- Davies SJ. "C3, 4, 5 Keeps the Diaphragm Alive." Is phrenic nerve palsy part of the pathophysiological mechanism in strangulation and hanging? Should diaphragm paralysis be excluded in survived cases?: A review of the literature. Am J Forensic Med Pathol 2010; 31:100.
- Murray JA, Demetriades D, Cornwell EE 3rd, et al. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma 1997; 43:624.
- Murray JA, Demetriades D, Asensio JA, et al. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998; 187:626.
- Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005; 58:789.
- Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma 1993; 34:822.
- Ochsner MG, Rozycki GS, Lucente F, et al. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma 1993; 34:704.
- Zellweger R, Navsaria PH, Hess F, et al. Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma. Br J Surg 2004; 91:1619.
- Bender JS, Lucas CE. Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports. J Trauma 1990; 30:1581.
- Edington HD, Evans S, Sindelar WF. Reconstruction of a functional hemidiaphragm with use of omentum and latissimus dorsi flaps. Surgery 1989; 105:442.
- Kamiyoshihara M, Nagashima T, Ibe T, Takeyoshi I. Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma. Gen Thorac Cardiovasc Surg 2010; 58:291.
- Sullivan RE. Strangulation and obstruction in diaphragmatic hernia due to direct trauma. Report of two cases and review of the English literature. J Thorac Cardiovasc Surg 1966; 52:725.
- ANATOMY OF THE DIAPHRAGM
- Diaphragmatic injury severity scale
- TRAUMA EVALUATION
- RECOGNITION OF DIAPHRAGMATIC INJURY
- Injury mechanism
- - Penetrating injury
- - Blunt diaphragmatic rupture
- Associated injuries
- Clinical evaluation
- - Delayed presentation
- DIAGNOSTIC EVALUATION
- Chest radiograph
- Computed tomography
- Magnetic resonance imaging
- Diagnostic peritoneal lavage
- Diagnostic dilemmas
- COMPLICATIONS OF DIAPHRAGMATIC INJURY
- Diaphragm paralysis
- Pulmonary complications
- Biliary fistula
- MANAGEMENT APPROACH
- Trauma laparotomy
- Use of mesh
- Managing cardiac herniation
- SUMMARY AND RECOMMENDATIONS