II. Causes

  1. Blunt Trauma to anterior Abdomen (MVA, fall from height)
    1. Increased abdominal pressure disrupts diaphragm
    2. High risk of pre-hospital mortality
    3. Associated injuries
      1. Large vessel injury (inferior vena cava, hepatic vein, aorta)
      2. Hemo-Pneumothorax (90% of cases), liver and Spleen injuries (25%)
      3. Pelvic Fracture (40%), long bone Fracture (75%) and multiple Rib Fractures
      4. Closed Head Injury (42%)
  2. Penetrating Trauma (Gunshot Wound, Stab Wound)
    1. Smaller, more occult diaphragm injuries at risk for Incarcerated Hernias
  3. Surgical complication

III. Imaging: Chest XRay

  1. First-line study
  2. Findings
    1. Stomach or bowel appears in the left chest
    2. Nasogastric Tube curled in the left chest
  3. Misdiagnoses (Diaphragmatic Rupture look-alikes)
    1. Elevated left hemidiaphragm
    2. Left loculated Pneumothorax
    3. Left subpulmonary hematoma

IV. Imaging: CT Chest

  1. Left sided Diaphragmatic Injury is most common
    1. Right side is shielded by the liver
    2. Bilateral injury is uncommon
  2. Efficacy (insufficient to completely exclude diaphragmatic perforation)
    1. Test Sensitivity: 82%
    2. Test Specificity: 88%
    3. Yucel (2015) Injury 46(9): 1734-7 +PMID:26105131 [PubMed]

V. Complications

  1. Herniation of Stomach, bowel, liver of Spleen
  2. Delayed diagnosis and repair
    1. Difficult repair outside the acute phase
    2. High morbidity and mortality from missed Diaphragmatic Rupture

VI. Symptoms

  1. Shoulder Pain
  2. Epigastric Pain
  3. Respiratory distress

VII. Management

  1. Emergent Trauma surgical Consultation and evaluation (Laparoscopy, thoracoscopy)
    1. Negative imaging (including CT) does not exclude Diaphragmatic Injury
    2. Laparoscopy and thoracoscopy are indicated in high suspicion cases (despite negative imaging)
    3. Missed Diaphragmatic Injury may result in serious complications

VIII. Prognosis

  1. Overall mortality
    1. Penetrating Diaphragmatic Injury: 4.3%
    2. Blunt Diaphragmatic Injury: 37%

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Ontology: Rupture of diaphragm (C0238088)

Concepts Injury or Poisoning (T037)
SnomedCT 83336007
Italian Rottura del diaframma
Japanese 横隔膜破裂, オウカクマクハレツ
English diaphragmatic rupture (diagnosis), diaphragmatic rupture, diaphragm rupture, rupture of diaphragm, Diaphragmatic rupture, Rupture of diaphragm, Rupture of the diaphragm, Rupture of diaphragm (disorder), diaphragm; rupture, rupture; diaphragm
Czech Ruptura bránice
Hungarian Rekesz ruptura
Dutch diafragma; ruptuur, ruptuur; diafragma, diafragmatische ruptuur
Spanish ruptura del diafragma (trastorno), ruptura del diafragma, ruptura diafragmática, Rotura diafragmática
Portuguese Ruptura diafragmática
French Rupture diaphragmatique
German Diaphragmaruptur