eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Diaphragmatic Injuries: Differential Diagnoses & Workup

Author: Michelle Welsford, MD, FRCP(C), FACEP, Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University; Staff Emergency Physician, Emergency and Prehospital Services, Medical Director, Paramedic Base Hospital Program, Hamilton, Ontario Health Sciences
Contributor Information and Disclosures

Updated: Oct 21, 2008

Differential Diagnoses

Abdominal Trauma, Blunt
Abdominal Trauma, Penetrating
Pneumothorax, Tension and Traumatic

Other Problems to Be Considered

Hemothorax
Pneumothorax
Pulmonary contusion
Blunt thoracic aortic tear
Elevated hemidiaphragm from other reasons

Workup

Imaging Studies

  • Chest radiography
    • Chest radiography is the single most important diagnostic study and may show elevation of the hemidiaphragm, a bowel pattern in the chest, or a nasogastric (NG) tube passing into the abdomen and then curling up into the chest. Additionally, a hemothorax, while not specific for diaphragmatic injuries, may be the only chest radiographic finding. The chest radiograph does not allow direct visualization of the diaphragmatic injury/defect but rather the associated herniation or other injuries. The initial chest radiograph is nondiagnostic in approximately 10-40% of patients. Repeated chest radiograph may be helpful. The chest radiographic findings may be masked if the patient is being positive-pressure ventilated (intubated) because this may reduce any herniation. Therefore, obtaining the chest radiograph before intubation or after extubation may be more helpful.
    • The liver often protects a right-sided rupture from visceral herniation, and, thus, these ruptures may appear only as an elevated hemidiaphragm from a partially herniated liver. Left-sided ruptures are more evident when the bowel is herniated into the chest.
    • Chest radiograph of a blunt left diaphragmatic injury often shows an abnormal or wide mediastinum, even when the aorta is normal. The mediastinum should be investigated because of the association with aortic injury discussed previously.
  • Ultrasonography is used commonly in trauma and may visualize large disruptions or herniation; however, it may miss small tears from penetrating injuries.
  • New-generation helical CT scanning is helpful but not 100% sensitive because of its poor visualization of the diaphragm. A diagnosis can be made if herniation of abdominal contents is visualized.
  • MRI may aid in the diagnosis because it can accurately visualize the diaphragm's anatomy. MRI may be used in a patient in stable condition who has an equivocal diagnosis and no need for laparotomy (some penetrating injuries) or for late diagnosis.
  • Thoracoscopy has been used to better visualize the diaphragm when the diagnosis is unconfirmed and laparotomy is not required.
  • When considering a delayed diagnosis, chest radiography and contrast studies (via NG or enema) often are used. MRI typically is an ideal diagnostic test in this instance.

Other Tests

  • Diagnostic peritoneal lavage
    • When diagnostic peritoneal lavage (DPL) is used to detect diaphragmatic injury, a false-negative result may occur. An isolated penetrating injury from the chest can cause bleeding into the lesser sac, which may not communicate with the rest of the peritoneal cavity. A DPL in this situation would show no evidence of bleeding.
    • Drainage of lavage fluid from the chest tube has been reported and is a positive result.
    • In blunt trauma, the DPL result is often positive because of the associated injuries and not specifically because of the diaphragmatic tear.
    • In penetrating chest injuries, most centers use 10,000 RBC/mm3, a more sensitive criterion than normally used, to limit the number of false-negative results.

More on Diaphragmatic Injuries

Overview: Diaphragmatic Injuries
Differential Diagnoses & Workup: Diaphragmatic Injuries
Treatment & Medication: Diaphragmatic Injuries
Follow-up: Diaphragmatic Injuries
References
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References

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Further Reading

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Keywords

diaphragmatic injuries, diaphragmatic injury, diaphragmatic rupture, diaphragmatic tear, diaphragm, abdominal injuries, diagnostic peritoneal lavage, blunt diaphragmatic ruptures, blunt trauma, penetrating trauma, knife wounds, gunshot wounds, motor vehicle crash, blunt traumatic injuries, penetrating traumatic injuries

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Contributor Information and Disclosures

Author

Michelle Welsford, MD, FRCP(C), FACEP, Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University; Staff Emergency Physician, Emergency and Prehospital Services, Medical Director, Paramedic Base Hospital Program, Hamilton, Ontario Health Sciences
Michelle Welsford, MD, FRCP(C), FACEP is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Canadian Association of Emergency Physicians, Canadian Medical Association, National Association of EMS Physicians, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

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, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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