DIAPHRAGMATIC INJURY

Department of surgery
Songkhla hospital
CONTENT
 Anatomy
 Etiology
 Mechanism of injury
 Associated injury
 Sign and symptom
 Diagnostic approach
 Complication of Diaphragmatic injury
 Management
ETIOLOGY

 DI 0.63% National Trauma Data Bank (NTDB)

 65 % Penetrating injury
 35 % Blunt injury
ASSOCIATED INJURY
 80-100% DI
 Spleen 50.0 %
 Rib 47.2 %
 Liver 38.9 %
 Lung 30.9 %
 Head 27.7 %
 Pelvic 27.7 %
 Other bones 30.5 %
 Bowel 19.4 %
 Kidney 13.9 %
 Great vessel 11.1 %
ASSOCIATED INJURY

 Rt.diaphragmatic injury
 Associated intraabdominal injury ~100%
 Lt.diaphargmatic hernia injury
 Associatedintraabdominal injury ~77%
 Descending aorta injury 5-8%
MECHANISM OF INJURY
 Penetrating injury
 stabs,gunshot, shotgun and impalements
 Small wound (1-3 cm.)

 Blunt injury
 More common in left side (3-4 times)
 Posterolateral aspect
 Bluntforce to abdomen or chest elevate
pressure > +150-200 cmH2O
 Wound size 5-10 cm.
SIGN AND SYMPTOM
 Early
 Shortness of breath
 Dyspnea
 Decreased breath sound
 Paradoxical movement of chest wall

 Late
 Abdominal pain
 Clinical of gut obstruction
 Audible bowel sound from chest area
DIAGNOSTIC

 Suspected DI in patient with

 Blunt injury
 Blunt thoracic or abdomen injury
 Multiple fracture lower rib

 Penetrating injury
 Thoracoabdominal area (T4-T12)
 Delayed presentation
 Herniation of abdominal organ
WORK UP

 Chest radiography
 Ultrasound

 Computer tomography

 Magnetic resonance imagine

 Laparoscopy

 Explore-Laparotomy
CHEST RADIOGRAPHY

 Visualization of the stomach or other

abdominal organs in the chest
 Elevation of the diaphragm

 Lack of clarity of the hemidiaphragm

 Abnormal positioning of a nasogastric tube

 Basilar atelectasis

 Hemothorax from bleeding in the abdomen

CHEST RADIOGRAPHY

 Collar sign
CHEST RADIOGRAPHY
ULTRASOUND

 FAST
 not standardized and a negative study
cannot be used to exclude the diagnosis
 Finding
 discontinuity of diaphragm
 Hernia

 Floating
diaphragm
 Nonvisualized diaphragm
DPL

 To improve its sensitivity for diagnosing

diaphragmatic injuries in penetrating
thoracoabdominal trauma, many clinicians
have modified the red blood count (RBC)
criteria, accepting lower RBC counts
(>10,000/mm3) to decrease the rate of false
negative results.
CT
 Discontinuity of the diaphragm
 Herniation of the abdominal contents into the chest
 Abnormal positioning of a nasogastric tube
 Waist-like constriction of bowel
 Viscera (liver, stomach) are in direct contact with the
posterior ribs
 Contiguous injury from one side of the diaphragm to
the other (ie, left pulmonary laceration and splenic
laceration)
 Sensitivity 82-87 % Specificity 72-99 % - in blunt
abdominal injury
CT

 Discontinuity of the diaphragm

CT

 Herniation of the abdominal contents into the

chest
CT

 Viscera (liver, stomach) are in direct contact

with the posterior ribs
MRI

 High suspicious with others negative studied

 Time-consuming

 Hemodynamic patient
MRI

CT MRI
LAPAROSCOPY

 High sensitivity and specificity especially in

penetrating injury
 Have benefit in case that no indication for
immediated surgery
EXPLORE-LAPAROTOMY

 Gold standard
 Unstable hemodynamic patient
DIAPHRAGM INJURY SCALE
 Grade I: Contusion
 Grade II: Laceration ≤2 cm
 Grade III: Laceration 2 to 10 cm
 Grade IV: Laceration >10 cm; tissue loss ≤25 cm2
 Grade V: Laceration and tissue loss >25 cm2
COMPLICATION
 Herniation
 Left side - stomach, spleen, colon, small intestine
omentum
 Right side - Liver or colon
 Cardiac herniation
 Diaphragm paralysis
 Pulmonary complication
 Rib fractures
 Pulmonary contusion
 Atelectasis
 Pleural effusion
 Empyema
 Biliary fistula
 biliary-pleural or bronchobiliary fistula formation
MANAGEMENT
 Acute setting
 Explor laparotomy - Midline laparotomy incision
 Suture from abdomen
: Small lacerations - interrupted, horizontal mattress,
or figure-of-eight stitches
: Larger lacerations - continuous or mesh
(0,1-0 monofilament nonabsorbable suture)
 Avoid Thoracotomy

 Chronic stage (Delayed diagnosis)

 Anterolateralthoracotomy
THANK YOU