Diaphragm Injury

Traumatic diaphragm rupture is a relatively uncommon traumatic injury, representing approximates 1% of all traumatic injuries. Blunt abdominal trauma being one of the etiologies, usually from high speed motor vehicle crashes or falls from a great height. With severe impact, there is a transfer of energy across the diaphragm from a sudden pressure gradient from compressive forces. Injury can also occur to the diaphragm secondary to ballistic penetrating trauma or from stab wounds both of which cause a small tear/rent in the diaphragm, as opposed to the radial tears seen with diaphragmatic rupture from blunt trauma. Approximately 65% of diaphragmatic injuries are secondary to penetrating etiologies as opposed to 35% from blunt trauma.

The occurrence of diaphragmatic rupture is a marker of severe impact and necessitates the need to probe for any other concomitant abdominal or thoracic injuries which occur in approximately 50% of traumatic diaphragm injuries. Thoracic injuries are composed of but not limited to fractured ribs, lung parenchymal tears or contusions. Injury to the stomach, small bowel, or spleen are seen within the abdominal cavity along with herniation of intra-abdominal organs into the thoracic cavity causing lung collapse and mediastinal shifting. Herniation of intra-abdominal organs tends to occur more frequently of the left. This phenomenon of left more so the right diaphragmatic ruptures is attributed to the protective shielding affects of the liver on the right side. When ruptures of the right diaphragm do occur, they are commonly associated with severe liver injury.

Diaphragmatic injury severity is classified into 5 grades.

Grade I: Contusion

Grade II: Laceration < 2 cm

Grade III: Laceration 2 to 10 cm

Grade IV: Laceration >10 cm or tissue loss "25 cm²

Grade V: Laceration and tissue loss > 25 cm²

Clinical evaluation should include assessing for signs of significant blunt force injuries and for diminished breath sounds which may indicate lung collapse from herniation. Patient with a delayed presentation may complain of nausea, vomiting, or abdominal pain which may indicate intestinal herniation and possible strangulation.

Diagnosis of diaphragmatic rupture is commonly confirmed by chest radiography revealing abdominal organs in the thoracic cavity or more subtly with elevation of the diaphragm, basilar atelectasis, unclear hemidiaphragms, or abnormal nasogastric tube positioning.

Treatment consists of surgical management of all left sides and most right sided diaphragmatic injuries. There are occasions when right sides injuries can be monitored secondary to the protective affects of the liver. Repair consists of reducing any herniation that has occurred, debriding any devitalized tissue, and primary closure when possible. If primary closure is not possible secondary to tissue loss, a non-absorbable, prosthetic mesh can be used unless gross colonic contamination has occurred. At that time, either an autologous tissue flap is used or a bioprosthesis.

References

Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EF (Eds), McGraw-Hill, 2008.

National Trauma Data Base. American College of Surgeons 2000-2004.

K. Vagholkar, S. Nair , S. Tople: Traumatic Diaphragmatic Rupture: A Diagnostic Challenge!. The Internet Journal of Thoracic and Cardiovascular Surgery. 2012 Volume 15 Number 2. DOI: 10.5580/2bb1

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.

Feliciano DV, Cruse PA, Mattox KL, et al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988; 28:1135.

Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002; 22 Spec No:S103.

Galketiya KP, Kerr JN, Davis IP. Blunt Diaphragmatic Rupture—a Rare Injury in Blunt Thoracoabdominal Trauma. Journal of Gastrointestinal Surgery 2012; 16(9):1805-6.

 

Thanks to Dr. Paul Balash for this submission.