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Diaphragmatic rupture

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Diaphragmatic rupture
Classification and external
resources

An X-ray showing the spleen in the
left lower portion of the chest cavity
(X and arrow) after a diaphragmatic
tear[1]
ICD-9 862.1
ICD-O: S27.8
med/3487
eMedicine
emerg/136

Diaphragmatic rupture (also called diaphragmatic injury or tear) is a tear of the
diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in
respiration. Most commonly, acquired diaphragmatic tears result from physical trauma.
Diaphragmatic rupture can result from blunt or penetrating trauma[2] and occurs in about
5% of cases of severe blunt trauma to the trunk.[3]

Diagnostic techniques include X-ray, computed tomography, and surgical techniques
such as laparotomy. Diagnosis is often difficult because signs may not show up on X-ray,
or signs that do show up appear similar to other conditions. Signs and symptoms included
chest and abdominal pain, difficulty breathing, and decreased lung sounds. When a tear is
discovered, surgery is needed to repair it.

Injuries to the diaphragm are usually accompanied by other injuries, and they indicate
that more severe injury may have occurred. The outcome often depends more on
associated injuries than on the diaphragmatic injury itself.[4] Since the pressure is higher

and the chest or abdomen may be painful. causing the presentation to be delayed.3–20% of cases. called traumatic diaphragmatic hernia.[8] With penetrating trauma.[2] Stab and gunshot wounds can cause diaphragmatic injuries.1 Complications  7 Epidemiology  8 History  9 References [edit] Signs and symptoms Breath sounds on the side of the rupture may be diminished. Contents [hide] [hide]  1 Signs and symptoms  2 Causes  3 Mechanism  4 Diagnosis o 4. penetrating trauma. social. . and blood supply can be cut off to organs that herniate through the diaphragm. damaging them. the contents of the abdomen may not herniate into the chest cavity right away.[6] and coughing is another sign. rupture of the diaphragm is almost always associated with herniation of abdominal organs into the chest cavity.[4] Since the diaphragm moves up and down during breathing.1 Location  5 Treatment  6 Prognosis o 6. vehicle accidents and falls are the most common causes.[5] This herniation can interfere with breathing.[4] Clinicians are trained to suspect diaphragmatic rupture particularly if penetrating trauma has occurred to the lower chest or upper abdomen.[7] In cases of blunt trauma.in the abdominal cavity than the chest cavity.[5] Bowel sounds may be heard in the chest. and shoulder or epigastric pain may be present.[3] Orthopnea. dyspnea which occurs when lying flat. but they may do so later. respiratory distress may be present. the main symptoms are those that indicate bowel obstruction. signs of intestinal blockage or sepsis in the abdomen may be present. but it has also been proposed as a more common cause than blunt trauma. for example during surgery to the abdomen or chest. [4] Injury to the diaphragm is reported to be present in 8% of cases of blunt chest trauma. may also occur.[4] Penetrating trauma has been reported to cause 12. and economic factors in the areas studied. discrepancies could be due to varying regional.[5] In people with herniation of abdominal organs. and by iatrogenic causes (as a result of medical intervention).[4] When the injury is not noticed right away.[4] [edit] Causes The injury may be caused by blunt trauma.

initial X-rays are normal. in addition to causing the rupture.[9] A blow to the side is three times more likely to cause diaphragmatic rupture than a blow to the front.[6] If ventilation of the lung on the side of the tear is severely inhibited. reducing cardiac output.[4] Half the time.[7] Another diagnostic method is laparotomy. penetrating injuries as high as the third rib and as low as the twelfth have been found to injure the diaphragm. diagnosis can be difficult. thus the condition is commonly diagnosed late.[9] [edit] Diagnosis Initially. but this is not usually possible because the patient is usually not stable enough. can also cause abdominal contents to herniate into the thoracic cavity.[6] Often diaphragmatic injury is discovered during a laparotomy that was undertaken because of another abdominal injury. the diaphram may appear higher than normal. especially when other severe injuries are present.[6] it has low sensitivity and specificity for the injury. this gradient. hypoxemia (low blood oxygen) results.[6] They can interfere with the return of blood to the heart and prevent the heart from filling effectively.[6] Usually the rupture is on the same side as an impact. On an X-ray. this sign is pathognomonic for diaphragmatic rupture.[3] Chest X-ray is known to be unreliable in diagnosing diaphragmatic rupture. thus it is usually taken from the front with the patient lying supine.5%. hemothorax or pneumothorax is present.[8] Although CT scanning increases chances that diaphragmatic rupture will be diagnosed before surgery. there are signs detectable on X-ray films that indicate the injury.[6] A contrast medium that shows up on X-ray can be inserted through the nasogastric tube to make a diagnosis.[6] However.[9] [edit] Mechanism Although the mechanism is unknown.[6] Thoracoscopy is more reliable in detecting diaphragmatic . it is proposed that a blow to the abdomen may raise the pressure within the abdomen so high that the diaphragm bursts.[5] Often another injury such as pulmonary contusion masks the injury on the X-ray film. but it is rare.[3] A nasogastric tube from the stomach may appear on the film in the chest cavity. and the mediastinum may appear shifted to the side.[6] Computed tomography has an increased accuracy of diagnosis over X-ray. but this misses diaphragmatic ruptures up to 15% of the time. in most of those that are not.[7] but no specific findings on a CT scan exist to establish a diagnosis.penetrating trauma to various parts of the torso may injure the diaphragm.[6] Abdominal contents in the pleural space interfere with breathing and cardiac activity. the rate of diagnosis before surgery is still only 31–43.[4] Blunt trauma creates a large pressure gradient between the abdominal and thoracic cavities.[5] Positive pressure ventilation helps keep the abdominal organs from herniating into the chest cavity. but this also can prevent the injury from being discovered on an X-ray.[3] The X- ray is better able to detect the injury when taken from the back with the patient upright.[3] Gas bubbles may appear in the chest.

injuries occurring on the left side are also easier to detect in X- ray films.[8] [edit] Epidemiology Diaphragmatic injuries are present in 1–7% of people with significant blunt trauma[4] and an average of 3% of abdominal injuries. but other injuries play a large role in determining outcome.[4] However.[5] [edit] Treatment Since the diaphragm is in constant motion with respiration.[4] [edit] Complications A significant complication of diaphragmatic rupture is traumatic diaphragmatic herniation: organs such as the stomach that herniate into the chest cavity and may be strangulated.[3] Herniation of abdominal organs is present in 3– 4% of people with abdominal trauma who present to a trauma center.[8] A high body mass index may be associated with a higher risk of diaphragmatic rupture in people involved in vehicle accidents.[8] Other injuries.tears than laparotomy and is especially useful when chronic diaphragmatic hernia is suspected. if the diaphragm is injured.[9] Surgery is needed to repair a torn diaphragm. is associated with a much higher death rate (mortality) than injury that occurs on just one side. losing their blood supply.[4] It is rare for the diaphragm alone to be injured. cushions the diaphragm.[4] Video-assisted thoracoscopy may be used.[6] [edit] Location Between 50 and 80% of diaphragmatic ruptures occur on the left side. which occurs in 1–2% of ruptures.[6] [edit] Prognosis In most cases. the injury is repaired during laparotomy.[5] It is possible that the liver.[3] Most of the time. isolated diaphragmatic rupture is associated with good outcome if it is surgically repaired.[4] The death rate (mortality) for diaphragmatic rupture after blunt and penetrating trauma is estimated to be 15–40% and 10–30% respectively. such as hemothorax. which is situated in the right upper quadrant of the abdomen.[9] Bilateral diaphragmatic rupture. and because it is under tension. the mortality . other injuries are associated in as many as 80–100% of cases. lacerations will not heal on their own.[6] Half of diaphragmatic ruptures that occur on the right side are associated with liver injury. it is an indication that more severe injuries to organs may have occurred. especially in blunt trauma.[5] Injuries occurring on the right are associated with a higher rate of death and more numerous and serious accompanying injuries. may present a more immediate threat and may need to be treated first if they accompany diaphragmatic rupture.[6][7] In fact.[7] Thus.

with most deaths due to lung complications. Radiol Clin North Am 44 (2): 199–211.[6] Associated injuries occur in over three quarters of cases. in Adams AP. ISBN 1-84110-117-6. fractures of the pelvis and long bones. ^ a b c d e f g h i j k l m n o Scharff JR. doi:10. 2.[8] Petit was the first to establish the difference between acquired and congenital diaphragmatic hernia. Thorac Surg Clin 17 (1): 81–5. Singhal R.[8] Reports of diaphragmatic herniation due to injury date back at least as far as the 17th century. Grounds RM. London: Greenwich Medical Media. pp. . Paré also described diaphragmatic rupture in people who had suffered blunt and penetrating trauma.com/1471-230X/6/38. doi:10. 3. in a French artillery captain who had been shot eight months before his death from complications of the rupture. Naumann repaired a hernia of the stomach into the left chest that was caused by trauma.[9] [edit] History Ambroise Paré In 1579. which results from a congenital malformation of the diaphragm. "Traumatic diaphragmatic injuries".after a diagnosis of diaphragmatic rupture is 17%. injuries to the aorta. ^ a b c d e f g h Nolan JP (2002).rcl. PMID 16500203. Kinra S.[7] Common associated injuries include head injury.1186/1471-230X-6-38. "Imaging of diaphragm injuries". 4. In 1888. "Post traumatic intra thoracic spleen presenting with upper GI bleed! A case report".biomedcentral.1016/j. http://www. ^ a b Sliker CW (March 2006). Ambroise Paré made the first description of diaphragmatic rupture. ^ Hariharan D. PMC: 1687187. Recent Advances in Anaesthesia and Intensive Care: Volume 22.[8] [edit] References 1. Chilton A (2006).10. Naunheim KS (February 2007). BMC Gastroenterol 6: 38. PMID 17650700.003. 182.2005. "Major trauma".[8] Using autopsies. and lacerations of the liver and spleen. PMID 17132174. vii. Cashman JN.

. Fifth Edition. PMID 15097979. in Moore EE.1016/j. Demitriades D. Mattox KL. viii–ix. Petrone P. 6. ^ a b c d e f g h i Asensio JA.002.".004.. Jurkovich GJ (March 2004).01. Henretig FM. McGraw-Hill Professional. "Blunt thoracic trauma".2007. ^ a b c d e f Weyant MJ. pp. 8. Emerg Med Clin North Am 25 (3): 695–711. Current Problems in Surgery 41 (3): 211–380. Ruddy RM.emc.5. ^ a b c d e f g h i j k l m n o p Karmy-Jones R. Rosen P (August 2007). "Blunt chest trauma".1016/j. 613–616. Textbook of Pediatric Emergency Medicine.004. Trauma. PMID 18420123. Hagerstown. This same pleuroperitoneal pressure gradient will also promote migration of intraperitoneal structures into the pleural space after disruption has occurred. doi:10. doi:10. Silverman BK. "Thoracic trauma". (2006). ^ a b c d e f g h McGillicuddy D. ISBN 0071370692. both cardiovascular and respiratory functions are compromised.2008. MD: Lippincott Williams & Wilkins. pp. ISBN 0-7817- 5074-1. commentary by Davis JW (2003). "A sudden increase in the pressure gradient between the pleural and peritoneal cavities that occurs with high-speed blunt trauma will lead to disruptions of the diaphragm.2003. PMID 17826213. 1446–7. Seminars in Thoracic and Cardiovascular Surgery 20 (1): 26–30. Feliciano DV..cpsurg.12. doi:10. 9. Ludwig S. "Injury to the diaphragm". ed. "Diagnostic dilemmas and current controversies in blunt chest trauma". 7. Once the viscera have been displaced into the pleural space.1053/j. ^ a b c d e f Fleisher GR.semtcvs. Fullerton DA (2008).06.