Diaphragm Injury

Diaphragm Injury

David Ray Velez, MD

Table of Contents

General
Diagnosis
Treatment

General

Definition: Injury of the Diaphragm

Most Common After Blunt Trauma

Site

  • Most Common on the Left
  • Most Common in the Posterolateral Aspect of the Hemidiaphragm Between the Lumbar and Intercostal Muscle Slips (Weakest Point)

Most Common Herniated Organs: Stomach and Colon

Complications

  • Respiratory Failure
  • Strangulation of Herniated Contents
  • Bowel Obstruction
  • Gastric Volvulus
  • Tension Gastrothorax

AAST Diaphragm Injury Scale

Typical Severity by Mechanism

  • Stabs and Low-Velocity GSW: Grade I-II
  • Blunt Trauma: Grade III-IV
  • High-Velocity GSW, Shotgun, or Explosion: Grade V

Diaphragm Laceration (Arrow) and Herniated Lung (Asterisk)

Diagnosis

Diagnosis Can Be Made Intraoperatively or Radiographically

Sensitivity

  • Plain Radiograph: Low Sensitivity (17-62% Sensitivity)
  • CT: Best Imaging Modality (56-87% Sensitivity with 75-100% Specificity)
  • eFAST/POCUS: Can Detect Signs but Highly Operator Dependent

Radiographic Signs

  • Unable to Trace the Normal Diaphragm Contour
  • Elevated Hemidiaphragm
  • Herniated Abdominal Organs (Gastric Bubble in the Chest)
  • Mediastinal Shift
  • NG Tube Above the Diaphragm
  • Collar Sign (Hourglass Sign): Waist-Like Constriction of Herniated Viscera at the Level of the Diaphragm
  • Cottage Loaf Sign: Collar Sign Involving the Liver Herniating Through a Right Diaphragm Defect, Similar Appearance to a Cottage Loaf
  • Dependent Viscera Sign: When Lying Supine, Herniated Organs Fall Against the Posterior Ribs Due to Loss of Diaphragm Support
  • Indirect Signs:
    • Hemothorax
    • Hemoperitoneum
    • Associated Rib Fracture
    • Associated Pulmonary Contusion

Traumatic Diaphragmatic Hernia on CXR

Collar Sign on CT

Treatment

Treatment

  • Contusion (Grade I): Conservative
  • Laceration (Grade II-V): Surgical Repair

Surgical Repair

  • Generally Repaired Primarily
  • Classically Described Using Permanent Sutures (Prolene) in Horizontal Mattress Fashion
  • Use Mesh if Large or Under Tension
    • Use Permanent Mesh
    • Consider Incision of Peripheral Attachments and Reattachment 2-3 Interspaces More Cephalad if Necessary
  • Reattach Diaphragm to Ribs if Completely Avulsed
    • Place Sutures Circumferentially Around the Ribs
    • May Also Consider Using Rib Suture Anchors

Surgical Timing/Approach

  • Early Diagnosis (< 1 Week): Transabdominal Approach
  • Delayed Diagnosis (> 1 Week): Transthoracic Approach
    • To Evaluate Viscera and Adhesions