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Diaphragm Rupture
Authors

Leslie V. Simon1; Richard A. Lopez2; Bracken Burns3.

Affiliations
1 Mayo Clinic Florida
2 Geisinger Medical Center
3 East Tennessee State University (ETSU)

Last Update: February 15, 2023.

Continuing Education Activity

Diaphragmatic injuries are relatively uncommon, representing less than 1% of traumatic injuries. They are typically
considered a marker of severe trauma due to the high rate of associated injury. While large diaphragmatic injuries may
be clinically obvious in the acute setting, diaphragmatic injuries are often occult, and a high index of suspicion must
be maintained to prevent missing this important diagnosis. A missed diaphragmatic injury may result in delayed
herniation and strangulation of abdominal organs into the thoracic cavity through the unrepaired defect in the
diaphragm. A thorough knowledge of the anatomy, associated injuries, and pitfalls in diagnostic testing will assist in
diagnosing this surgical condition. This activity reviews the workup of diaphragm rupture and describes the role of
health professionals working together to managing this condition.

Objectives:

Review the presentation of a patient with diaphragmatic rupture.

Outline the treatment of diaphragmatic rupture.

Describe the surgical approach to diaphragmatic rupture.

Summarize the role of health professionals working together as an interprofessional team in managing this
condition.

Access free multiple choice questions on this topic.

Introduction
The diaphragm is the arched, flat muscular structure that divides the thorax from the abdominal cavity. Diaphragmatic
injuries are relatively uncommon, representing less than 1% of traumatic injuries. They are typically considered a
marker of severe trauma due to the high rate of associated injury. Certain injury patterns increase the risk of
diaphragmatic injury, and penetrating trauma is a more common mechanism than blunt trauma. While large
diaphragmatic injuries may be clinically obvious in the acute setting, diaphragmatic injuries are often occult, and a
high index of suspicion must be maintained to prevent missing this important diagnosis. A missed diaphragmatic
injury may result in delayed herniation and strangulation of abdominal organs into the thoracic cavity through the
unrepaired defect in the diaphragm. A thorough understanding of the anatomy, associated injuries, and pitfalls in
diagnostic testing will assist in diagnosing this surgical condition.[1][2][3][4]

Etiology
Injury to the diaphragm may be due to penetrating or blunt trauma. Penetrating trauma with direct injury to the
diaphragm is more common and accounts for about two-thirds of cases. Stab wounds are the most frequent etiology,
followed by gunshot wounds and impalements. Penetrating trauma usually results in smaller, unilateral injuries, which
are more likely to be missed in the initial evaluation. The remaining one-third is due to blunt trauma with the vast

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majority (90%) caused by motor vehicle crashes. Falls and crush injuries account for the remainder. Blunt trauma
causes larger ruptures; up to one-third of these ruptures may be bilateral.

Epidemiology
Like most traumatic conditions, the diaphragmatic injury is more common in males. Patients with blunt injuries tend
to be older with a median age of 44 years. In contrast, those with penetrating injuries have a median age of 31 years.
Patients with blunt injury also have higher injury severity scores (33 versus 24). More than 50% of patients with
diaphragmatic injury will have significant associated injuries. Mortality varies with the mechanism and is reported at
25% for all patients diagnosed with a diaphragmatic injury. Mortality is greatest in patients with blunt injury
mechanisms in the acute setting due to associated injuries. The mortality from delayed presentation with herniation of
abdominal contents into the thorax, from previous penetrating trauma, is around 20% and is substantially higher when
bowel strangulation occurs. Since small injuries to the diaphragm are frequently missed, the exact incidence is
unknown but is reported in the National Trauma Data Bank at about 0.5%. The rate of diaphragmatic injury appears to
be increasing, perhaps related to better early trauma care, enhanced detection, and increased survival rates in patients
with severe injuries.[5][6][7][8]

Pathophysiology
Penetrating Diaphragmatic Injury

The diaphragm separates the negative pressure thorax from the positive pressure abdomen and spans from the lower
sternum anteriorly to as low as L3 posteriorly. Depending on the phase of respiration, the location can be quite
variable, and wounds that appear to be remote from its perceived location may violate the diaphragm. Any penetrating
injury to the abdomen or chest from the T4 through T12 dermatome anteriorly and the L3 region posteriorly should be
considered to have potentially caused the diaphragmatic injury. Left-sided injuries are more common, possibly due to
protective shielding by the liver but also perhaps due to the mechanism as most are related to stabbings and assailants
are more likely to be right-handed thus inflicting injuries on the victim’s left. Penetrating injuries tend to be smaller,
most measuring less than 2 cm. As a result, penetrating injuries are more likely to be occult and frequently result in
delayed diagnosis. Penetrating injuries are most commonly associated with liver, hollow viscous, and splenic injuries.

Blunt Diaphragmatic Injury

Rupture of the diaphragm occurs when intra-abdominal pressure suddenly rises above the tensile strength of the
diaphragmatic tissue. Blunt trauma produces larger, radial tears, often measuring 5 cm to 15 cm. Like penetrating
injury, blunt diaphragmatic injuries occur most frequently on the left side which may be due to a congenital area of
weakness in the diaphragm or because the liver attenuates some of the compressive force. When present, right-sided
injuries to the diaphragm have a higher mortality rate due to more severe associated injuries. As compared to
penetrating injuries, patients with blunt injury have a higher rate of injury to the aorta, lung, pelvis, and spleen.

Diaphragmatic injuries rarely occur alone and most patients have concomitant abdominal, head or thoracic injuries.
Splenic rupture and liver laceration are not uncommon injuries in patients with diaphragmatic trauma.

History and Physical

Clinical presentation varies widely based on the mechanism of injury. Because the diaphragm is integral to normal
respiration, patients with diaphragmatic injury may present in respiratory distress. Most often, blunt diaphragmatic
injuries are discovered during the evaluation and management of the associated injuries. A physical exam should
focus on the airway, breathing, and circulation, with inspection for signs of mediastinal shift or lung displacement.
When herniation of abdominal contents occurs, bowel sounds may be auscultated in the chest. Any patient with
penetrating trauma in the zone of concern (described above) should be assessed for diaphragmatic injury. Less than
half of diaphragmatic injuries are diagnosed preoperatively, and a high index of suspicion based on the mechanism is
required.

The physical exam should concentrate on the ABCDEs with a focus on the neck and chest. Some patients may have
tracheal deviation, absent breath sounds, or asymmetrical chest expansion.

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In most cases, the diagnosis is not made preoperatively and in 10-50% of patients, the diagnosis may be delayed for
days or weeks. When patients present late, they usually have visceral or bowel herniation into the chest cavity.
Strangulation, incarceration and even cardiac tamponade have been described in patients with delayed presentation.

Evaluation
Chest Radiography

While findings may be obvious if there are bowel contents or a coiled nasogastric tube in the chest, chest radiographs
are non-diagnostic in up to 40% of cases. This is particularly true in intubated patients as positive pressure ventilation
prevents herniation of abdominal contents into the chest. Subtle findings may include elevation of the diaphragm,
atelectasis or pleural effusion. Right-sided injuries, unless resulting in large defects, may be particularly difficult to
identify on chest radiographs as the liver buttresses the diaphragm.

Ultrasound

Ultrasound is frequently utilized in the early evaluation of trauma patients to assess for fluid in the abdomen,
pericardium, and chest. An experienced operator may be able to visualize an injury to the diaphragm, but a negative
study does not exclude the diagnosis.

Computed tomography (CT)

In hemodynamically stable patients, CT scanning may be useful in detecting diaphragmatic injury. Newer generation
multidetector machines may detect even subtle injuries with a sensitivity of around 66.7%. However, most patients
with penetrating injury still do not receive a correct preoperative diagnosis.

Thoracoscopy or Laparoscopy

Thoracoscopy may be used to visualize the diaphragm when the diagnosis is considered, but laparotomy is not
required to manage other injuries. Laparoscopy has a sensitivity of about 88% and a sensitivity of nearly 100% in
evaluating for diaphragmatic injury.

Treatment / Management
In the emergency department, a meticulous trauma evaluation with the management of the airway, breathing, and
circulation is most important. Placement on an oral or nasogastric tube may be helpful in making the diagnosis if the
tube remains in the chest and in decompressing the stomach contents thus preventing further herniation. In some
settings, a chest tube, inserted carefully to avoid causing additional injury, should be placed to address associated
hemothorax or pneumothorax. Injuries to the diaphragm do not heal spontaneously, so operative repair is required in
almost all patients.

All left-sided injuries require repair, as do most right-sided injuries. In the rare patient with a small, right-sided tear
that is a candidate for expectant management, it is important for the patient to understand the risk of delayed rupture.
Surgical management is often via a transabdominal approach, typically during the laparotomy performed for other
injuries. In less severely injured patients, a less invasive laparoscopic or even thoracoscopic approach may be
appropriate.[9]

The actual repair is simple; once the herniated contents have been reduced, the rupture to the diaphragm can be closed
with interrupted non-absorbable sutures. A chest tube should be left in the chest for a few days.

Differential Diagnosis

Pneumothorax

Blunt/Penetrating abdominal trauma

Pneumoperitoneum

Prognosis

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The prognosis for patients who are managed right away is good. Early deaths are most often due to other associated
injuries. Re-expansion pulmonary edema has been reported after laparotomy in rare cases. Sometimes diaphragmatic
paralysis may occur if the laceration was in the vicinity of the phrenic nerve. However, in most cases, resolve over a
few months.

Complications

Complications include:

Bowel herniation, incarceration, strangulation

Tension pneumothorax/hemothorax

Pericardial tamponade

Enhancing Healthcare Team Outcomes

The diagnosis of a diaphragmatic rupture is not easy, especially when the tear is small. Hence, the condition is best
managed by an interprofessional team that includes a radiologist, general surgeon, thoracic surgeon, and a trauma
surgeon. Nurses who look after patients with penetrating or blunt trauma should be aware of missed diaphragmatic
injuries. Difficulties in breathing, bowel sounds in the chest and an abnormal chest x-ray should be a concern and
reported to the surgeon.

Once diagnosed, the only treatment for a diaphragmatic tear is surgery. The surgery may be approached via the
abdomen or thorax. Nurses should ensure that these patients have DVT and pressure sore prophylaxis. If a chest tube
has been left in after surgery, it should be monitored for air and fluid leaks. Open communication between the team
members is vital for good outcomes.

In most cases, if there are no other injuries, the outcomes are excellent. However, if the diagnosis is missed, it can
present later with herniation of bowel contents in the chest.[10] (Level V)

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

References
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[PubMed: 28529538]
9. Memon MA, Fitztgibbons RJ. The role of minimal access surgery in the acute abdomen. Surg Clin North Am.
1997 Dec;77(6):1333-53. [PubMed: 9431343]
10. Weaver AA, Schoell SL, Talton JW, Barnard RT, Stitzel JD, Zonfrillo MR. Functional outcomes of thoracic
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PMC6776991] [PubMed: 29584488]
Disclosure: Leslie Simon declares no relevant financial relationships with ineligible companies.

Disclosure: Richard Lopez declares no relevant financial relationships with ineligible companies.

Disclosure: Bracken Burns declares no relevant financial relationships with ineligible companies.

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Figures

CT scan of a grade IV-V splenic injury. CXR suggests a left hemidiaphragm rupture. Contributed by Mark
Pellegrini (Public Domain)

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CXR showing a nasogastric tube noted to terminate in the left chest cavity with a left diaphragm rupture.
Contributed by Patrizio Petrone et al.

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