Diaphragmatic Injury in Adults

Recognition and management of diaphragmatic injury in adults
10/8/14 10:55 PM
19.3

TOPIC OUTLINE
INTRODUCTION
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
Ultrasound
Computed tomography
Magnetic resonance imaging
Diagnostic peritoneal lavage
Diagnostic dilemmas
COMPLICATIONS OF DIAPHRAGMATIC INJURY
Herniation
Diaphragm paralysis
Pulmonary complications
Biliary fistula
MANAGEMENT APPROACH
SURGERY
Preparation
Trauma laparotomy
Use of mesh
Managing cardiac herniation
MORTALITY
SUMMARY AND RECOMMENDATIONS
REFERENCES
GRAPHICSView All
FIGURES
Anatomy and innervation of the diaphragm
Diaphragm surfaces
Left phrenic nerve course
Right phrenic nerve course
Thoracic dermatomes
file:///Users/DrHamilton/Dropbox/UpToDate/UpToDate19.3/UpToDate19.3/contents/mobipreview.htm?37/17/38160
Page 1 of 14
10/8/14 10:55 PM
Diaphragm plication
PICTURES
Chest radiograph with rupture of the left hemidiaphragm
Diaphragmatic injury with left hemidiaphragm discontinuity
Diaphragmatic injury with herniation
RELATED TOPICS
Abdominal gunshot wounds

Abdominal stab wounds
Causes and diagnosis of bilateral diaphragmatic paralysis
Diseases of the chest wall
General approach to blunt abdominal trauma in adults
General approach to blunt thoracic trauma in adults
General approach to penetrating thoracic trauma in adults
Inpatient management of traumatic rib fractures
Massive blood transfusion
Nasogastric and nasoenteric tubes
Overview of control measures to prevent surgical site infection
Overview of indications for and complications of ERCP and endoscopic biliary sphincterotomy
Surgical management of splenic injury in the adult trauma patient
Treatment of diaphragmatic paralysis
Author
Section Editors
Mallory Williams, MD, MPH, FACS Heidi L Frankel, MD, FACS
Richard Turnage, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated:
Thu Feb 17 00:00:00 GMT 2011 (More)
INTRODUCTION 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
Page 2 of 14
10/8/14 10:55 PM
elsewhere. (See "General approach to blunt thoracic trauma in adults" and "General approach to
penetrating thoracic trauma in adults" and "General approach to 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.
The costal and crural fibers insert into the central tendon (figure 1). The anterior portion of the tendon
attaches to the posterior aspect of the xiphisternal junction. The posterior portion of the central tendon
attaches to the first three lumbar vertebral bodies (L1-L3). Lateral insertions of the central tendon occur
on the 6th rib anteriorly and the 12th rib posteriorly.
The vascular supply of the diaphragm is derived from the phrenic artery below the diaphragm and the
pericardiophrenic arteries above the diaphragm (figure 2). The phrenic nerve originates from the anterior
rami of C3, C4 and C5 and traverses the neck and mediastinum before inserting into the diaphragm
centrally (figure 3 and figure 4). The outer rim of the diaphragmatic muscle is innervated laterally from
the T7 through T12 (figure 1). The crural group of muscles receives innervation from the vagus nerve
[3].
Diaphragmatic injury severity scale Diaphragm injuries are classified according to the American
Association for the Surgery of Trauma (AAST) organ injury scale. Increased morbidity and mortality has
been correlated with increasing injury grade for some injuries (eg, liver, spleen, kidney), but to date, not
for diaphragmatic injuries. The diaphragmatic injury severity scale is as follows:
Grade
Grade
Grade
Grade
Grade
I: Contusion
II: Laceration 2 cm
III: Laceration 2 to 10 cm
IV: Laceration >10 cm; tissue loss 25 cm2
V: Laceration and tissue loss >25 cm2
TRAUMA EVALUATION The initial resuscitation, diagnostic evaluation, and management of the
patient with blunt or penetrating injury is based upon protocols from the Advanced Trauma Life Support
(ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial
resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is
discussed elsewhere. (See "General approach to blunt abdominal trauma in adults" and "General
approach to blunt thoracic trauma in adults" and "Abdominal stab wounds" and "Abdominal gunshot
Page 3 of 14
10/8/14 10:55 PM
wounds".)
In the setting of acute trauma, many patients cannot relate their symptoms or medical history due to
altered mental status (eg, neurologic injury, intoxication) or because they are intubated and sedated.
Every attempt should be made to identify preexisting medical conditions by contacting the patient's
primary care physician or family members. The presence of significant medical comorbidities and medical
conditions requiring antiplatelet or anticoagulation should be determined, as these may impact
management decisions.
RECOGNITION OF DIAPHRAGMATIC INJURY Studies using the National Trauma Data Bank
(NTDB), the largest trauma registry in the world, have found an overall incidence of diaphragm injury of
0.63 percent [2]. A suspicion for diaphragmatic injury begins with the identification of the injury
mechanism, physical examination of the patient and assessment of associated injuries. Certain injury
patterns increase the risk for diaphragmatic injury.
Injury mechanism The diaphragm can be injured directly, due to an impalement or missile passing
through it from the abdominal cavity to the thoracic cavity or vice versa, or indirectly from blunt rupture,
which is caused by a sudden increase in intra-abdominal pressure that is sufficient to overcome the
strength of the diaphragmatic tissue. Blunt diaphragm rupture usually causes large radial tears of the
diaphragm, while penetrating injury leads to smaller rents that approximate the size of the penetrating
impalement. As such, penetrating injuries are more likely to be missed. (See 'Delayed
presentation' below.)
Penetrating injury Penetrating mechanisms to the thoracoabdominal region, such as stabs,
gunshot, shotgun and impalements, account for about 65 percent of all diaphragmatic injuries [2]. The
diaphragm can rise as high as the fourth thoracic (T4) dermatome on the right and the fifth dermatome
(T5) (figure 5) on the left with deep inspiration, and it descends to as low as the eighth thoracic
dermatome (T8) with expiration. The lowest level of the lateral diaphragm attachment is the base of the
12th rib. Thus, any impalement or missile that passes through the chest or abdominal wall from T4
through T12 has the potential to injure the diaphragm. Penetrating injury due to stabbing is more
common on the left compared with the right, presumably because the majority of assailants are righthanded, assuming a frontal assault.
Blunt diaphragmatic rupture Blunt mechanisms account for the remaining 35 percent of
diaphragmatic injuries and occur in 0.8 to 1.6 percent of patients sustaining blunt trauma. Motor vehicle
collisions are responsible for up to 90 percent of blunt diaphragm rupture with the remainder due to falls
or crush injury, both of which can sufficiently elevate intra-abdominal pressure to rupture the diaphragm
[2,4,5].
When the diaphragm contracts, the relaxed dome-shaped diaphragm flattens which increases the volume
of the thoracic cavity, decreases the volume of the abdominal cavity and changes intrapleural and intraabdominal pressure. During normal quiet breathing, intraperitoneal pressure ranges from +2 to +10 cm
water (H20) and intrapleural pressure is from -5 to -10 cm water which results in a pleuroperitoneal
gradient of +7 to +20 cm H20 in the supine position. With maximal inspiration, the diaphragm is forced
downward and the pleuroperitoneal pressure gradient can rise as high as +100 cm H20. Changes in the
compliance of the abdominal or chest wall alter normal mechanics. (See "Diseases of the chest wall",
section on 'Normal structure and function'.)
The application of blunt force to the abdomen or chest can result in pleuroperitoneal gradients of +150 to
200 cm H20, which exceeds the strength of the muscle or tendinous tissues, and can rupture or avulse
Page 4 of 14
10/8/14 10:55 PM
the diaphragm from its attachments. (See 'Anatomy of the diaphragm' above.)
The left diaphragmatic leaflet is two to three times more likely than the right leaflet to be injured with
blunt trauma [6-8]. Bilateral blunt rupture of the diaphragm occurs in 2 to 6 percent of patients [9]. In
one retrospective study of 731 patients with traumatic diaphragm rupture, the left posterolateral region
medial to the spleen was the most common site of injury [8]. This is felt to be due to a congenital
weakness of this region. Another explanation may be that the liver protects the right diaphragm by
attenuating or preventing the transmission of force across the diaphragm. However, a tendency toward
more right-sided diaphragmatic injuries is observed as collision speed increases [10].
Associated injuries At least 50 percent of patients with diaphragmatic injury also suffer associated
injuries [8,11].
For penetrating trauma, the passage of an impalement or missile through the abdominal or chest walls
rarely injures the diaphragm in isolation [2,8]. In one study, 75 percent of patients with penetrating
diaphragmatic injury had an associated organ injury [6]. In another study, an average of two organ
injuries were present in patients who suffered stab wounds and three organ injuries in those patients
sustaining gunshot wounds [7].
For blunt trauma, the percent of patients with a given injury who also have a traumatic diaphragmatic
rupture are: liver (48 percent), hemothorax and/or pneumothorax (47 percent), spleen (35 percent), rib
fracture (28 percent), bowel (23 percent), kidney (16 percent), pelvic fracture (14 percent), closed head
injury (11 percent), thoracic aorta (4 percent), and spinal cord injury (4 percent) [2].
Clinical evaluation The patients abdomen and chest should be examined for the presence of
contusions or ecchymoses that might suggest that significant blunt forces have been sustained. Although
diaphragmatic excursion depends upon variables such as body build, body posture and lung volume, any
bullet or stab wound between the level of the T4 and T12 dermatomes (figure 5) has the potential to
cause diaphragmatic injury, particularly if penetrating wounds are found on both sides of the diaphragm.
Penetrating wounds in the posterior or flank region of the trunk can also lead to diaphragmatic injury.
(See 'Anatomy of the diaphragm' above.)
The presence of a rent in the diaphragm can lead to acute herniation of abdominal contents into the
chest. The finding of diminished breath sounds may indicate collapse of the lung due to herniation. If the
stomach has herniated, air injected into the nasogastric tube may be heard in the chest upon
auscultation although this finding is non-specific. (See "Nasogastric and nasoenteric tubes", section on
'Confirmation of placement'.)
Delayed presentation The trauma patient may initially have no symptoms or signs to suggest an
injury to the diaphragm or associated injuries may be sufficiently severe that definitive evaluation for
diaphragmatic injury is delayed. With time, the diaphragmatic defect due to injury has a tendency to
become larger, and herniation of abdominal organs becomes more likely, particularly if left-sided. In one
small series of delayed diagnosis of traumatic diaphragm rupture, 3 of 16 patients (19 percent) had their
injuries missed at initial laparotomy [12]. The majority of these injuries (15 out of 16) were on the left
[12]. Small right-sided injuries may remain stable because the liver tamponades the defect preventing
bowel herniation.
Patients with previous thoracoabdominal penetrating trauma or motor vehicle collisions who present with
abdominal pain and nausea/vomiting should be evaluated for a possible missed diaphragmatic injury as a
cause of gastrointestinal obstruction due to herniation. Failure to diagnose and repair the diaphragm can
lead to intestinal strangulation and, potentially, death.
Page 5 of 14
10/8/14 10:55 PM
DIAGNOSTIC EVALUATION The mechanism of injury and physical exam findings may suggest the
need for additional studies beyond the plain chest x-ray that is typically obtained during the primary
survey during trauma resuscitation. A diagnosis of diaphragmatic injury is often coincidentally made
while using computed tomography (CT) to rule out significant life-threatening injuries (eg, traumatic
aortic rupture) [13]. Small tears may not be seen even with sophisticated imaging techniques; however,
higher resolution multidetector CT scanning appears to hold the most promise. (See 'Computed
tomography' below.)
Chest radiograph The chest radiograph is the most commonly obtained imaging study used for the
evaluation of trauma patients. Diagnosis of diaphragmatic injury on chest radiograph can be as obvious
as visualization of the stomach or other abdominal organs in the chest, or suggested by subtle signs
including elevation of the diaphragm, basilar atelectasis, lack of clarity of the hemidiaphragm, or even
hemothorax from bleeding in the abdomen (eg, splenic injury) (picture 1).
Ultrasound The Focused Assessment with Sonography in Trauma (FAST) examination is an important
component of trauma management that is used primarily to detect free intraperitoneal blood following
trauma. (See "General approach to blunt abdominal trauma in adults", section on 'Ultrasound'.)
Ultrasound techniques can also be used to evaluate the diaphragm, but the use of ultrasound to identify
traumatic diaphragmatic rupture is not standardized and a negative study cannot be used to exclude the
diagnosis [14-16]. To perform the examination, a 5.0 to 7.5 MHz linear array transducer is placed
transversely on the abdomen with the transducer directed posteriorly toward the diaphragm. The
diaphragm appears as a hyperechoic (ie, white) line superior to the liver. The diaphragm is followed from
right to left and its continuity evaluated.
Findings on ultrasound consistent with diaphragmatic injury include discontinuity of the diaphragm,
herniation of the liver or bowel loops through a diaphragmatic defect, floating diaphragm, and
nonvisualization of the diaphragm. Indirect findings include pleural effusion or subphrenic fluid collection.
Computed tomography Following blunt thoracoabdominal trauma, computed tomography (CT) is
often performed as part of the initial trauma evaluation or based upon findings of a chest radiograph. CT
is most commonly used in hemodynamically stable patients as a means to rule out solid organ and
hollow viscus injuries.
CT can detect diaphragm injury and is more useful for assessing the posterior lumbar elements of the
diaphragm (crura and arcuate ligaments) compared with the anterior leaflets. Portions of the diaphragm
may be obscured due to a similarity in attenuation levels to adjacent structures (eg, liver, spleen).
Findings on CT scan suggestive of diaphragm injury include:
Discontinuity of the diaphragm (picture 2)
Herniation of the abdominal contents into the chest (picture 3)
Abnormal positioning of a nasogastric tube
Waist-like constriction of bowel
Dependence of the viscera meaning that the viscera (liver, stomach) are in direct contact with the
posterior ribs
Contiguous injury from one side of the diaphragm to the other (ie, left pulmonary laceration and
Page 6 of 14
10/8/14 10:55 PM
splenic laceration)
In the available studies, 4 or 16 slice CT scanners have a sensitivity of 82 to 87 percent and specificity of
72 to 99 percent for detecting diaphragmatic injury due to penetrating trauma [17,18]. However, first
and second generation imaging studies were prone to missing centrally located radial tears. Some of the
limitations of earlier scanners are being overcome with newer helical and multidetector (up to 256 slice)
computed tomography (MDCT) studies, which are able to acquire volumetric data, eliminate motion
artifact and can provide excellent three-dimensional reconstruction [19]. However, because of the rarity
of diaphragmatic injury, the sensitivity and specificity for detecting diaphragmatic injury with advanced
CT technology has yet to be established. We expect the accuracy to be improved due to better
longitudinal and in-plane image resolution.
Even with higher resolution scans, injuries can be missed in intubated patients on positive pressure
ventilation because the abdominal organs that might have herniated into the chest are pushed back into
the abdomen. Sagittal reconstructions may be helpful to define the injury in these patients. Where
available, multidetector CT scanning is the primary diagnostic modality for identifying patients who
require repair of a diaphragmatic injury. However, many hospitals, including some Level I trauma
centers, may not have the benefit of these high-resolution scanners which may alter the management
approach. (See 'Management approach' below.)
Magnetic resonance imaging Magnetic resonance imaging (MRI) can be time-consuming to
perform, and often places the patient in a hospital location that is remote from ready access and
intervention. For this reason, MRI does not play a significant role in the initial evaluation of the injured
patient. However, MRI may be applicable in a subset of hemodynamically stable patients who cannot
undergo computed tomography (eg, allergic to IV contrast) or in those for whom a suspicion for
diaphragmatic injury remains high in spite of other negative diagnostic studies [20].
Diagnostic peritoneal lavage Diagnostic peritoneal lavage (DPL) was commonly used in the past,
but has been supplanted by the Focused Assessment with Sonography for Trauma (FAST) examination
and other imaging modalities for the diagnosis of diaphragmatic injury. The interpretation of DPL is
discussed elsewhere. (See "General approach to blunt abdominal trauma in adults", section on
'Diagnostic peritoneal lavage'.)
DPL may still play a role in the evaluation of penetrating thoracoabdominal trauma [21]. To improve its
sensitivity for diagnosing diaphragmatic injuries in penetrating thoracoabdominal trauma, many clinicians
have modified the red blood count (RBC) criteria, accepting lower RBC counts (5000 to 10,000/mm3) to
decrease the rate of false negative results.
Diagnostic dilemmas Imaging studies may be falsely positive for diaphragmatic injury; such occurs
with eventration of the diaphragm and Chilaiditis sign.
Eventration of the diaphragm is due to thinning and elevation of the diaphragm in such a manner
that pneumoperitoneum or herniation of bowel seems to be present above the diaphragm.
Eventration of the diaphragm is thought to be due to a congenital defect of the diaphragm or an
acquired defect from complete or incomplete paralysis of the diaphragm. Hypoplasia of the lung on
the involved side may contribute to the etiology in the congenital variant. The acquired variant
usually occurs on the right side. If suspected, previous imaging studies, if available, should be
compared with images obtained at the time of trauma admission.
Chilaiditi's sign can also lead to a false positive diagnosis of diaphragmatic injury [22]. Chilaiditi's
Page 7 of 14
10/8/14 10:55 PM
sign is due to a loop of bowel interposed between the liver and the diaphragm. Although the
involved bowel is usually transverse colon, it can also be distended small bowel. When associated
with abdominal pain, this entity is known as Chilaiditi's syndrome.
COMPLICATIONS OF DIAPHRAGMATIC INJURY Overall morbidity associated with diaphragmatic
injury ranges from 30 to 68 percent and is related to the presence of associated injuries [7,23,24].
Patients suffering blunt trauma have higher complication rates (60 percent) compared with those who
have penetrating trauma (40 percent) [25].
Herniation The true incidence of abdominal organ herniation due to diaphragmatic injury is unknown
since many cases likely go undiagnosed. Herniation of the stomach, spleen, colon, small intestine and
omentum occur on the left and, on the right, the liver or colon. Cardiac herniation has also been
reported.
Patients with prior thoracoabdominal trauma who present with signs and symptoms consistent with
gastrointestinal obstruction or ischemia should be evaluated for a possible missed diaphragmatic injury.
(See 'Delayed presentation' above.)
Diaphragm paralysis The diaphragm is the major muscle of respiration, and during quiet breathing,
its contraction is responsible for 75 to 80 percent of tidal volume. With unilateral paralysis of the
diaphragm, the normal hemidiaphragm descends normally, while the paralyzed hemidiaphragm moves
upward. The resultant mediastinal shift reduces lung capacity by as much as 20 to 30 percent. (See
"Causes and diagnosis of bilateral diaphragmatic paralysis", section on 'Altered function with
diaphragmatic paralysis'.)
Although phrenic nerve injury associated with trauma is more commonly seen with high cervical spine
injuries or penetrating neck trauma, injury to the phrenic nerves can occur as a result of
thoracoabdominal trauma and its management such as during emergent thoracotomy or repair of injuries
to mediastinal structures. Phrenic nerve injury can also be due to diaphragm tears [26]. Patients with
traumatic diaphragm paralysis who require ventilator support beyond two weeks may be candidates for
diaphragmatic plication.
Diaphragm plication fixes a paralyzed hemidiaphragm in the flat position, decreasing its paradoxical
movement and improving the overall efficiency of mechanical ventilation without impairing the potential
for the recovery of diaphragm function (figure 6). The treatment of diaphragm paralysis is discussed
elsewhere. (See "Treatment of diaphragmatic paralysis", section on 'Surgical plication'.)
Pulmonary complications Diaphragmatic injury is often accompanied by rib fractures and
pulmonary contusion. Pulmonary complications are common with atelectasis occurring in 11 to 68
percent of patients, pleural effusion in 10 to 23 percent, and empyema in 2 to 10 percent with
diaphragmatic injury [7,23,24]. Diagnosis and management of these complications are discussed in
individual topics reviews. (See "Inpatient management of traumatic rib fractures".)
Biliary fistula Combined injury of the liver, diaphragm and lung can lead to biliary-pleural or
bronchobiliary fistula formation. Biliary drainage from the thoracostomy tube establishes the diagnosis of
biliary-pleural fistula. Bronchobiliary fistula occurs due to penetrating mechanisms that traverse a
bronchus and biliary radical. The presenting symptom may be bilioptysis (coughing up bile).
The management of these traumatic fistulae is similar to biliary fistulae from other causes. Patients who
develop fever, chills, or leukocytosis should undergo computed tomography of the chest and abdomen to
identify any pleural fluid collections which should be percutaneously drained and cultured. The presence
Page 8 of 14
10/8/14 10:55 PM
of bile confirms the presence of a biliary-pleural fistula. A HIDA scan can also be used for the diagnosis.
Endoscopic retrograde cholangiopancreatography (ERCP) defines the anatomy of the injury and
potentially offers treatment with sphincterotomy and/or biliary stent placement. (See "Overview of
indications for and complications of ERCP and endoscopic biliary sphincterotomy".)
MANAGEMENT APPROACH Patients undergoing exploratory laparotomy for trauma for other reasons
should have a thorough inspection of the diaphragm as a part of the trauma laparotomy. (See 'Trauma
laparotomy' below.)
All left-sided diaphragm injuries and most right-sided injuries require repair when recognized. Acute
injuries are usually repaired using an abdominal approach. The force needed to cause blunt
diaphragmatic injury is significant and although diaphragmatic injury can be isolated, it is more likely to
be associated with other injuries that may need repair. Similarly, abdominal exploration is generally
indicated for penetrating injuries. (See 'Associated injuries' above.)
Some patients with severe associated injuries may require delayed management of the diaphragmatic
injury.
The timeframe over when an acute injury becomes chronic is subject to debate. Once the repair becomes
elective and there is no longer a concern for concomitant injury, the possibility of minimally invasive
repair from either an abdominal or thoracic approach increases [27,28]. Chronic diaphragmatic hernia is
typically repaired with a thoracic approach.
Hemodynamically stable patients with a negative physical exam and imaging studies can be observed.
Small asymptomatic right-sided injuries that are tamponaded by the liver have a low risk for significant
long-term sequelae and can also be managed expectantly.
If the index of suspicion is high for diaphragmatic injury, but imaging studies have been inconclusive, an
alternative approach is to use minimally invasive techniques (laparoscopy, thoracoscopy) to confirm (or
rule out) a diaphragmatic injury and potentially repair it with minimally invasive techniques [27,29-31].
Although there is the theoretical concern for pneumothorax with insufflation of the abdomen in patients
with diaphragmatic injury, this has not been described in the literature. We prefer to prepare the chest
along with the abdomen in the event that a chest tube is needed.
Laparoscopy has a sensitivity of 88 percent and a specificity approaching 100 percent in the diagnosis of
diaphragmatic injury [29]. In one retrospective review of 119 patients with left-sided penetrating
thoracoabdominal trauma, 31 percent of the patients found to have diaphragmatic injury on laparoscopy
had no abdominal tenderness and normal chest radiograph was seen in 40 percent [27]. One-fourth of
patients did not have sufficient clinical signs and/or radiology examination to diagnose the injury.
Thoracoscopy can also be used to diagnose diaphragmatic injury. In a small series of 14 patients, all
injuries of the diaphragm were detected with thoracoscopy [31].
When diaphragmatic injury is identified on laparoscopy or thoracoscopy, it may not be amenable to
repair with minimally invasive techniques necessitating conversion to open surgery.
SURGERY
Preparation The patient (or the patient's next of kin if the patient is intubated or unresponsive)
should be informed that although exploration is being performed to manage identified injuries, other
intra-abdominal injuries may be discovered that need specific management. (See 'Associated
injuries' above.)
Page 9 of 14
10/8/14 10:55 PM
Blood products should be available in the event the patient becomes hemodynamically unstable. A
trauma transfusion protocol should be in place including packed red blood cells, fresh frozen plasma, and
platelets. (See "Massive blood transfusion".)
Prophylactic antibiotics are administered to prevent surgical site infection. For emergent trauma surgery,
antibiotic selection is the same as for elective surgery with administration of a first generation
cephalosporin (eg, cefazolin). If there is concern for or confirmed enteric, or colorectal contamination,
anaerobic coverage with metronidazole is appropriate (see "Overview of control measures to prevent
surgical site infection").
Trauma laparotomy A midline trauma laparotomy incision is used to evaluate the abdomen and
retroperitoneum and rule out or repair identified injuries. Control of hemorrhage and gastrointestinal
spillage are the first priorities. (See "Surgical management of splenic injury in the adult trauma patient",
section on 'Exploratory laparotomy'.)
The abdominal surface of the diaphragm should be included as part of a standard abdominal exploration.
After ligation and division of the falciform ligament, the right hemidiaphragm is inspected by downward
traction on the liver. The liver does not usually need to be mobilized away from its coronary ligamentous
attachments. Downward traction on the fundus of the stomach and dome of the spleen allows
visualization of the left hemidiaphragm. The central tendon, the esophageal hiatus and the diaphragmatic
crura at the aortic hiatus should also be inspected to ensure they remain firmly attached to the lumbar
vertebrae and are not torn.
When herniation of abdominal organs is present, the organs should be gently reduced from the
diaphragmatic defect back into the abdominal cavity. With chronic herniation, there is always a hernia
sac with adhesions. Dissection of the hernia sac away from the abdominal contents is first necessary;
then the abdominal organs can be reduced without causing injury. Any serosal or capsular tears that
occur are identified and repaired.
The edges of the diaphragmatic defect are grasped with Allis clamps. The thoracic cavity is inspected
through the defect for contamination or ongoing hemorrhage. If contamination exists, copious lavage is
performed. Irrigation of the thoracic cavity through a laparotomy approach has been shown to be
effective in controlling biliary, gastric or enteric contamination in patients with penetrating trauma [32].
Any devitalized diaphragmatic tissue is debrided. The diaphragm is repaired with permanent suture or
absorbable monofilament suture (Size 0, 1) in a running or interrupted fashion. Gentle downward
traction of the cardiac surface of the diaphragm away from the heart during the placement of sutures will
avoid inadvertent cardiac injury. In rare cases of massive diaphragmatic and chest wall destruction,
other surgical options are available (eg, diaphragm transposition) [33].
The diaphragm has an excellent blood supply (figure 2) and breakdown of repairs is generally
uncommon. However, infection can contribute to breakdown of the repair. Antibiotics should be given
prophylactically prior to surgery and are continued postoperatively only when indicated. (See
'Preparation' above.)
Use of mesh In the rare instance that primary repair is not possible due to excess diaphragmatic
tissue loss or chronic expansion of the defect (Grade IV or V injury), nonabsorbable prosthetic materials
(eg, polytetrafluoroethylene, polyethylene) can be used, provided no colonic contamination is present.
When contamination is present, the abdomen is copiously irrigated and an autologous tissue flap (eg,
omentum, latissimus dorsi flap), or a bioprosthesis should be used [34].
Page 10 of 14
10/8/14 10:55 PM
Managing cardiac herniation Acute cardiac herniation is usually due to high-speed motor vehicle
collision [35]. The heart herniates inferiorly into the peritoneal cavity due to disruption of the central
tendon. The diagnosis is established with chest radiograph or FAST examination. Repair of this injury is
through a laparotomy incision.
MORTALITY The mortality for diaphragmatic injury depends upon the trauma mechanism and
presence of associated injuries. The National Trauma Databank (NTDB) reports an overall mortality of 25
percent for patients with diaphragmatic injury [2]. The immediate 24-hour mortality from diaphragmatic
injuries is due to associated injuries. Mortality is higher with blunt compared with penetrating injury due
to the presence of significant associated thoracic or abdominal injuries [8].
Poor physiologic status upon presentation of the patient accompanied by continued hemorrhage is a
predictor of death [8]. The mortality for delayed presentation of diaphragmatic injury for the patient with
incarceration of gastrointestinal contents is about 20 percent, increasing to 40 to 57 percent when bowel
strangulation is present [36].
SUMMARY AND RECOMMENDATIONS
The diaphragm is the musculotendinous boundary between the negative-pressure thoracic cavity
and positive-pressure abdominal cavity and plays a significant role in normal respiratory function.
(See 'Anatomy of the diaphragm' above.)
Diaphragmatic injury is uncommon, representing less than one percent of all traumatic injuries.
The diaphragm is usually injured in association with other thoracic and abdominal organs. A high
index of suspicion for this injury is needed because delayed diagnosis is associated with an
increased risk for herniation and strangulation of abdominal organs, which can be life-threatening.
Penetrating injury leads to smaller rents which are more likely to be missed compared with blunt
rupture which typically causes large radial tears. (See 'Recognition of diaphragmatic injury' above.)
A suspicion for diaphragmatic injury begins with the identification of the injury mechanism,
physical examination and assessment of associated injuries. Direct injury to the diaphragm is due
to an implement or missile passing through the diaphragm. Indirect injury is caused by a sudden
increase in intra-abdominal pressure that is sufficient to overcome the strength of the
diaphragmatic tissues resulting in blunt rupture. (See 'Injury mechanism' above.)
Blunt traumatic injuries that are highly associated (>30 percent) with diaphragmatic injury include
hemothorax, liver injury and splenic injury. Any penetrating mechanism found to involve organs on
either side of the diaphragm is likely to be associated with a diaphragmatic injury. (See 'Associated
injuries' above.)
The mechanism of injury and physical exam findings may suggest the need for additional studies
beyond plain chest radiograph. Computed tomography (CT) is the primary imaging modality used
to diagnose diaphragmatic injury. Features consistent with diaphragmatic injury on CT scan include
discontinuity of the diaphragm, herniation of abdominal contents into the chest, abnormal
Page 11 of 14
10/8/14 10:55 PM
positioning of the nasogastric tube, or other subtle findings. Alternative modalities include
ultrasound or MRI. Small tears, particularly right-sided penetrating injuries, may not be identified
by any imaging modality. (See 'Diagnostic evaluation' above.)
Laparoscopic or thoracoscopic exploration may be appropriate to obtain a diagnosis (and an
opportunity for repair) in the patient for whom a high index of suspicion for diaphragmatic injury
persists in spite of negative imaging studies. (See 'Management approach' above.)
All left-sided diaphragmatic injuries and most right-sided injuries should be repaired when
recognized. Acute injuries of the diaphragm are repaired from the abdomen, often in conjunction
with abdominal exploration to identify and repair other associated injuries. (See 'Management
approach' above.)
Hemodynamically stable patients with a negative physical exam and imaging studies can be
observed. Small right-sided diaphragmatic injuries in hemodynamically stable patients can be
managed expectantly. Patients who are being observed should be monitored for signs or symptoms
that suggest herniation. (See 'Management approach' above.)
The diaphragm is repaired primarily unless a large defect is present, in which case prosthetic
materials are used provided there is no colonic contamination. (See 'Surgery' above.)
The overall mortality associated with diaphragmatic injury is 25 percent primarily due to the
presence of life-threatening chest or abdominal injury but can also result from complications of the
injury itself. Complications of diaphragmatic injury include gastrointestinal herniation, pulmonary
sequelae due to altered respiratory mechanics, diaphragm paralysis, and pleural fistula. Of these
complications, gastrointestinal herniation contributes to mortality the most due to bowel ischemia
and infarction. (See 'Mortality' above and 'Complications of diaphragmatic injury' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES
1. Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EF (Eds), McGraw-Hill, 2008..
2. National Trauma Data Base. American College of Surgeons 2000-2004.
3. Young RL, Page AJ, Cooper NJ, et al. Sensory and motor innervation of the crural diaphragm by the
vagus nerves. Gastroenterology 2010; 138:1091.
4. Hedblom, CA. Diaphragmatic hernia: A study of three hundred and seventy eight cases in which
operation was performed. JAMA 1925; 85:947.
5. Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma:
analysis of 60 patients. J Trauma 1986; 26:438.
6. Demetriades D, Kakoyiannis S, Parekh D, Hatzitheofilou C. Penetrating injuries of the diaphragm. Br
J Surg 1988; 75:824.
7. Wiencek RG Jr, Wilson RF, Steiger Z. Acute injuries of the diaphragm. An analysis of 165 cases. J
Thorac Cardiovasc Surg 1986; 92:989.
8. 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.
9. Bergin D, Ennis R, Keogh C, et al. The "dependent viscera" sign in CT diagnosis of blunt traumatic
Page 12 of 14
10/8/14 10:55 PM
diaphragmatic rupture. AJR Am J Roentgenol 2001; 177:1137.

10. May AK, Moore MM. Diagnosis of blunt rupture of the right hemidiaphragm by technetium scan. Am
Surg 1999; 65:761.
11. Shanmuganathan K, Killeen K, Mirvis SE, White CS. Imaging of diaphragmatic injuries. J Thorac
Imaging 2000; 15:104.
12. Feliciano DV, Cruse PA, Mattox KL, et al. Delayed diagnosis of injuries to the diaphragm after
penetrating wounds. J Trauma 1988; 28:1135.
13. Bhavnagri SJ, Mohammed TL. When and how to image a suspected broken rib. Cleve Clin J Med
2009; 76:309.
14. 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.
15. Kim HH, Shin YR, Kim KJ, et al. Blunt traumatic rupture of the diaphragm: sonographic diagnosis. J
Ultrasound Med 1997; 16:593.
16. Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture. Am J Emerg Med
2010; 28:387.e1.
17. 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.
18. Bodanapally UK, Shanmuganathan K, Mirvis SE, et al. MDCT diagnosis of penetrating diaphragm
injury. Eur Radiol 2009; 19:1875.
19. Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge?
Radiographics 2002; 22 Spec No:S103.
20. 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.
21. 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.
22. Kamiyoshihara M, Ibe T, Takeyoshi I. Chilaiditi's sign mimicking a traumatic diaphragmatic hernia.
Ann Thorac Surg 2009; 87:959.
23. Payne JH Jr, Yellin AE. Traumatic diaphragmatic hernia. Arch Surg 1982; 117:18.
24. Chen JC, Wilson SE. Diaphragmatic injuries: recognition and management in sixty-two patients. Am
Surg 1991; 57:810.
25. Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Occult marker of serious injury. Ann Surg
1993; 218:783.
26. 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.
27. 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.
28. 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.
29. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after
penetrating abdominal trauma. J Trauma 2005; 58:789.
30. Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal
Page 13 of 14
10/8/14 10:55 PM
trauma. J Trauma 1993; 34:822.

31. 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.
32. Zellweger R, Navsaria PH, Hess F, et al. Transdiaphragmatic pleural lavage in penetrating
thoracoabdominal trauma. Br J Surg 2004; 91:1619.
33. Bender JS, Lucas CE. Management of close-range shotgun injuries to the chest by diaphragmatic
transposition: case reports. J Trauma 1990; 30:1581.
34. Edington HD, Evans S, Sindelar WF. Reconstruction of a functional hemidiaphragm with use of
omentum and latissimus dorsi flaps. Surgery 1989; 105:442.
35. 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.
36. 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.
Page 14 of 14

Diaphragmatic Injury in Adults

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Diaphragmatic Injury in Adults

Încărcat de

Drepturi de autor:

Formate disponibile

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Abdominal gunshot wounds

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Recognition and management of diaphragmatic injury in adults

Use of UpToDate is subject to the Subscription and License Agreement.

Recognition and management of diaphragmatic injury in adults

diaphragmatic rupture. AJR Am J Roentgenol 2001; 177:1137.

Recognition and management of diaphragmatic injury in adults

trauma. J Trauma 1993; 34:822.

S-ar putea să vă placă și