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.
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- 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