Diaphragmatic Injuries Clinical Presentation

  • Author: Michelle Welsford, MD, FACEP, FRCPC(Canada); Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 08, 2015
 

History

Clinical presentation varies depending on the mechanism of injury (ie, blunt vs penetrating) and the presence of associated injuries. Symptoms of diaphragmatic injuries frequently are masked by associated injuries. The diaphragm is integral to normal ventilation, and injuries can result in significant ventilatory compromise. A history of respiratory difficulty and related pulmonary symptoms may indicate diaphragmatic disruption.

Diaphragmatic tears rarely occur in isolation. These patients often have associated thoracic and/or abdominal injuries or may have concomitant head or extremity trauma. The rates for associated injuries in blunt diaphragmatic rupture are as follows:

  • Pelvic fractures in 40%
  • Splenic rupture in 25%
  • Liver laceration in 25%
  • Thoracic aortic tear in 5-10%

Diaphragmatic rupture and thoracic aortic disruption are uniquely associated in blunt trauma. In a retrospective chart review, 1.8% of patients with blunt trauma had a diaphragmatic rupture, 1.1% had a thoracic aortic tear, and 10.1% had both.[5] In this last group, the mechanism for all was a high-speed MVC. This association, although rare, is important to consider. The review authors suggested that when one diagnosis is evident, the clinician should further investigate the possibility of the other associated injury.

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Physical

The physical examination should focus initially on airway, ventilation, and circulation, with concomitant management of airway, ventilatory, or circulatory compromise. Examination of the neck and chest should include a particular focus on findings of tracheal deviation (ie, mediastinal shift), symmetry of chest expansion, and absence of breath sounds (ie, lung displacement). Since the incidence of associated injuries is high, physical findings typically are dictated by these other injuries.

  • Early diagnosis
    • Diagnosis may not be obvious. It is made preoperatively in only 40-50% of left-sided and 0-10% of right-sided blunt diaphragmatic ruptures. In 10-50% of patients, diagnosis is not made in the first 24 hours.
    • Traumatic diaphragmatic injuries are just one of many injuries that can cause acute respiratory compromise.
    • Physical examination is limited in its utility in diagnosing this injury, but diaphragm injury may be identified by auscultation of bowel sounds in the chest or dullness on percussion of the chest. A penetrating injury to the abdomen with a suggestion of a lung or thoracic injury indicates transgression of the diaphragm as would a chest injury with any suggestion of abdominal injury.
  • Delayed diagnosis
    • If not made in the first 4 hours, the diagnosis may be delayed for months or years. Thus, 10-50% of blunt injuries (and an even greater percentage in penetrating trauma) are diagnosed late. This number is decreasing because of greater awareness and earlier identification.
    • Although the diagnosis may be missed regardless of mechanism, seemingly innocent penetrating injuries may be long forgotten by the patient and are the most commonly missed diaphragmatic injury.
  • The 3 clinical phases of diaphragmatic injuries were first described by Grimes. [6]
    • The first, or acute, phase begins with the injury.
    • If not diagnosed early, the second, or latent, phase occurs. This phase is asymptomatic but may evolve into gradual herniation of abdominal contents. The diagnosis may be made later because of complications of herniation of abdominal contents into the pleural cavity.
    • The third, or obstructive phase, is characterized by bowel or visceral herniation, obstruction, incarceration, strangulation, and possible rupture of the stomach and colon. If herniation causes significant lung compression, it can lead to tension pneumothorax. Cardiac tamponade has been described from herniation of abdominal contents into the pericardium. Diaphragmatic paralysis also may occur.
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Causes

The 2 primary mechanisms of traumatic diaphragmatic injuries are blunt or penetrating trauma. Blunt traumatic injuries occur most commonly from MVCs or falls. Penetrating injuries most commonly occur from gunshot or knife injuries to the chest or abdomen.

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Contributor Information and Disclosures
Author

Michelle Welsford, MD, FACEP, FRCPC(Canada) Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University School of Medicine; Staff Emergency Physician, Hamilton Health Sciences; Medical Director, Centre for Paramedic Education and Research

Michelle Welsford, MD, FACEP, FRCPC(Canada) is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Ontario Medical Association, Canadian Association of Emergency Physicians, Canadian Medical Association, National Association of EMS Physicians, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
  1. Carter BN, Giuseffi J, Felson B. Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther Nucl Med. 1951 Jan. 65(1):56-72. [Medline].

  2. Baloyiannis I, Kouritas VK, Karagiannis K, Spyridakis M, Efthimiou M. Isolated right diaphragmatic rupture following blunt trauma. Gen Thorac Cardiovasc Surg. 2011 Nov. 59(11):760-2. [Medline].

  3. Melo EL, de Menezes MR, Cerri GG. Abdominal gunshot wounds: multi-detector-row CT findings compared with laparotomy-a prospective study. Emerg Radiol. 2011 Dec 2. [Medline].

  4. Berardoni NE, Kopelman TR, O'Neill PJ, August DL, Vail SJ, Pieri PG, et al. Use of computed tomography in the initial evaluation of anterior abdominal stab wounds. Am J Surg. 2011 Oct 27. [Medline].

  5. Rizoli SB, Brenneman FD, Boulanger BR, Maggisano R. Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex. Ann Thorac Surg. 1994 Nov. 58(5):1404-8. [Medline].

  6. Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg. 1974 Aug. 128(2):175-81. [Medline].

  7. Dreizin D, Bergquist PJ, Taner AT, Bodanapally UK, Tirada N, Munera F. Evolving concepts in MDCT diagnosis of penetrating diaphragmatic injury. Emerg Radiol. 2015 Apr. 22 (2):149-56. [Medline].

  8. Patlas MN, Leung VA, Romano L, Gagliardi N, Ponticiello G, Scaglione M. Diaphragmatic injuries: why do we struggle to detect them?. Radiol Med. 2015 Jan. 120 (1):12-20. [Medline].

  9. Leung VA, Patlas MN, Reid S, Coates A, Nicolaou S. Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre. Can Assoc Radiol J. 2015 Jun 19. [Medline].

  10. Athanassiadi K, Kalavrouziotis G, Athanassiou M, et al. Blunt diaphragmatic rupture. Eur J Cardiothorac Surg. 1999 Apr. 15(4):469-74. [Medline].

  11. Barbiera F, Nicastro N, Finazzo M, et al. The role of MRI in traumatic rupture of the diaphragm. Our experience in three cases and review of the literature. Radiol Med (Torino). 2003 Mar. 105(3):188-94. [Medline].

  12. Barsness KA, Bensard DD, Ciesla D, et al. Blunt diaphragmatic rupture in children. J Trauma. 2004 Jan. 56(1):80-2. [Medline].

  13. Bergqvist D, Dahlgren S, Hedelin H. Rupture of the diaphragm in patients wearing seatbelts. J Trauma. 1978 Nov. 18(11):781-3. [Medline].

  14. Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging. Emerg Radiol. 2012 Jun. 19(3):225-35. [Medline].

  15. Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma. 1993 Aug. 35(2):255-60. [Medline].

  16. Boulanger BR, Mirvis SE, Rodriguez A. Magnetic resonance imaging in traumatic diaphragmatic rupture: case reports. J Trauma. 1992 Jan. 32(1):89-93. [Medline].

  17. Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg. 1995 Jul. 170(1):5-9. [Medline].

  18. Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008 Mar. 85(3):1044-8. [Medline].

  19. Jarrett F, Bernhardt LC. Right-sided diaphragmatic injury: rarity or overlooked diagnosis?. Arch Surg. 1978 Jun. 113(6):737-9. [Medline].

  20. Leaman PL. Rupture of the right hemidiaphragm due to blunt trauma. Ann Emerg Med. 1983 Jun. 12(6):351-7. [Medline].

  21. Leppaniemi A, Haapiainen R. Occult diaphragmatic injuries caused by stab wounds. J Trauma. 2003 Oct. 55(4):646-50. [Medline].

  22. Matsevych OY. Blunt diaphragmatic rupture: four year's experience. Hernia. 2008 Feb. 12(1):73-8. [Medline].

  23. Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury. 2003 Mar. 34(3):169-72. [Medline].

  24. Nau T, Seitz H, Mousavi M, Vecsei V. The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc. 2001 Sep. 15(9):992-6. [Medline].

  25. Patselas TN, Gallagher EG. The diagnostic dilemma of diaphragm injury. Am Surg. 2002 Jul. 68(7):633-9. [Medline].

  26. Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA, Fischer PE, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May. 39(5):530-4. [Medline].

  27. Ramos CT, Koplewitz BZ, Babyn PS, et al. What have we learned about traumatic diaphragmatic hernias in children?. J Pediatr Surg. 2000 Apr. 35(4):601-4. [Medline].

  28. Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma. 1986 May. 26(5):438-44. [Medline].

  29. Sangster G, Ventura VP, Carbo A, et al. Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients. Emerg Radiol. 2006 Nov 29. [Medline].

  30. Schneider CF. Traumatic diaphragmatic hernia. Am J Surg. 1956 Feb. 91(2):290-7. [Medline].

  31. Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: spectrum of radiographic findings. Radiographics. 1998 Jan-Feb. 18(1):49-59. [Medline].

  32. Shatney CH, Sensaki K, Morgan L. The natural history of stab wounds of the diaphragm: implications for a new management scheme for patients with penetrating thoracoabdominal trauma. Am Surg. 2003 Jun. 69(6):508-13. [Medline].

  33. Shehata SM, Shabaan BS. Diaphragmatic injuries in children after blunt abdominal trauma. J Pediatr Surg. 2006 Oct. 41(10):1727-31. [Medline].

  34. Sukul DM, Kats E, Johannes EJ. Sixty-three cases of traumatic injury of the diaphragm. Injury. 1991 Jul. 22(4):303-6. [Medline].

  35. Tansley P, Treasure T. Trauma care and the pitfalls of diaphragmatic rupture. J R Soc Med. 1999 Mar. 92(3):134-5. [Medline].

  36. Voeller GR, Reisser JR, Fabian TC, et al. Blunt diaphragm injuries. A five-year experience. Am Surg. 1990 Jan. 56(1):28-31. [Medline].

  37. Zarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC. Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg. 2013 Jun. 74(6):1392-8; quiz 1611. [Medline].

 
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