Journal Pre-proof

Imaging Evaluation of Diaphragmatic Injuries: Improving Interpretation

Accuracy

Fabio M. Paes (Conceptualization) (Resources) (Investigation)

(Writing - original draft) (Writing - review and editing) (Visualization),
Anthony M. Durso (Resources) (Investigation) (Writing - original
draft), Gary Danton (Resources) (Investigation) (Writing - original
draft), Ivan Castellon (Resources) (Visualization), Felipe Munera
(Conceptualization) (Supervision) (Writing - original draft) (Writing -
review and editing)

PII: S0720-048X(20)30323-5
DOI: https://doi.org/10.1016/j.ejrad.2020.109134
Reference: EURR 109134

To appear in: European Journal of Radiology

Received Date: 9 March 2020

Revised Date: 10 June 2020
Accepted Date: 15 June 2020

Please cite this article as: Paes FM, Durso AM, Danton G, Castellon I, Munera F, Imaging
Evaluation of Diaphragmatic Injuries: Improving Interpretation Accuracy, European Journal of
Radiology (2020), doi: https://doi.org/10.1016/j.ejrad.2020.109134
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© 2020 Published by Elsevier.

Imaging Evaluation of Diaphragmatic Injuries: Improving Interpretation Accuracy

Authors: Fabio M Paes, Anthony M Durso, Gary Danton, Ivan Castellon and Felipe

Munera.

Affiliation: Department of Diagnostic Radiology, University of Miami - Leonard Miller

School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami FL (all

authors)

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Corresponding Author: Fabio M Paes, MD, MBA.

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Address: 1611 NW 12th Ave, West Wing Room 279, Miami FL 33136, USA

Phone: (+1) 305-585-2448

Fax: (+1) 305-585-5743

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E-mail: fpaes@med.miami.edu
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Highlights

 Diaphragmatic injury is a severe finding that remains a diagnostic challenge.

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 Early detection of DI is essential to prevent life-threatening complications.

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 MDCT should be used for screening of traumatic diaphragmatic injury.

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Abstract

Diaphragmatic Injuries (DIs) remain a challenging diagnosis with potential catastrophic

delayed complications. A high degree of suspicion in every case of severe blunt

thoracoabdominal trauma or penetrating thoracoabdominal injury is essential. This

review will present the evidence and controversies on this topic providing a practical

tutorial for radiologists hoping to improve their interpretive accuracy for both blunt and

penetrating DIs. The imaging signs of diaphragmatic injuries will be explained with

emphasis on multidetector CT. Diagnostic pitfalls, available protocols and other issues

will be presented.

Abbreviations: DI – Diaphragmatic Injury; DR – Diaphragmatic Rupture; MDCT –

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Multidetector Computer Tomography

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Key Words: Diaphragmatic Injury, Blunt, Penetrating, Trauma, MDCT

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This research did not receive any specific grant from funding agencies in the public,

commercial or not-for-profit sectors.

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Introduction:
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Diaphragmatic injury (DI) is a rare but severe traumatic finding that remains a diagnostic

challenge to radiologists and surgeons. Early detection followed by surgical repair are
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essential to prevent life-threatening complications such as bowel herniation into the

thoracic cavity with the potential for strangulation [1]. Imaging diagnosis of acute
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traumatic diaphragmatic injury is difficult and greatly underreported, particularly in the

absence of organ herniation into the chest [2].

The estimated incidence of diaphragmatic rupture (DR) is approximately 0.8-8% in blunt

abdominal trauma and 10-15% in penetrating injuries [3, 4]. Although penetrating
trauma has a higher incidence of diaphragmatic injury, blunt trauma is responsible for

most cases due to its higher prevalence (80-85% blunt vs 15-20% penetrating) [1].

Approximately 90% of blunt traumatic diaphragmatic ruptures result from high energy

motor vehicle collisions [5].

Most diaphragmatic injuries caused by blunt trauma are large (about 10–

15 cm defect), involves the left diaphragm (56–86% of cases) and have radial

morphology [1, 5]. Right hemidiaphragm ruptures represent only 11–39% of the blunt

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traumatic cases [1]. The relative rareness of right-sided injuries may be due to a

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“protective” effect of the liver on the right hemidiaphragm, although underdiagnosis may

also play a role [1].

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Penetrating diaphragmatic injury (PDI) presentation is significantly different from blunt
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diaphragmatic rupture. Traumatic tears are often small (averaging less than 2 cm in

85% of cases) and difficult to detect in the early post-traumatic assessment period. In
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contrast to the large defects typically observed on blunt trauma, findings of PDI can be

subtle on Multidetector Computer Tomography (MDCT), usually presenting as a small

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defect without organ or fat herniation [6].

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Relevant Anatomy

A cupula-shaped structure separating the bottom of the pleural space from top of the
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abdomen, the diaphragm consists of a large central tendon, with circumferential right

and left skeletal muscular leaflets and three dominant openings: the aortic hiatus,

esophageal hiatus, and inferior vena cava foramen [5]. MDCT allows the visualization of

the right and left crus (tendinous structures) that continue as the anterior longitudinal
ligament along the right side of L1-L3 and left side of L1-L2 vertebrae respectively. By

crossing anteriorly and meeting at the midline, the two crura form the medial arcuate

ligament in front of the aorta. Posterolaterally, the tendinous arches that covers the

quadratus lumborum muscles on each side are known as the lateral arcuate ligament,

which can be congenitally discontinuous on imaging in approximately 11% of patients

[7]. The anterior or costal segments of the diaphragm insertion are often more difficult to

visualize than the lumbar parts on axial images.

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Only the diaphragmatic areas centrally delineated by fat planes will be well portrayed on

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imaging. The presence of organs with similar density abutting the diaphragm, such as

the spleen or liver, and the conventional tangential plane of imaging acquisition prevent

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accurate visualization and explains the diagnostic limitations of axial CT images for
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diagnosing traumatic diaphragmatic tears. Therefore, the multiplanar reformats with

coronal and sagittal planes are crucial for the adequate imaging evaluation of the
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diaphragm [5, 6].

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MDCT imaging technique

The use of faster MDCT scanners has become standard of care for imaging of injured
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patients in most trauma centers. Rapid imaging acquisition of the entire torso minimize

respiratory and motion artifacts allowing better visualization of the diaphragm. Imaging
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acquisition protocol vary significantly among institutions, but independent of the MDCT

protocol used, it is important to acquire thin slices and near isotropic datasets which

permit adequate multiplanar reformat reconstructions [6, 8]. Our scanning protocol

involves acquisition of both arterial and portal venous phase images with fixed delays of
30 and 70 seconds respectively. We use 0.6 mm collimation and reconstruct images at

1.5 mm with 50% overlap for 3D processing. Multiplanar reformats with coronal and

sagittal planes are performed routinely and oblique reformations are obtained

selectively. We routinely administer 100-120 mL of IV contrast (350 mg/ml, ioversol:

Mallinckrodt; Hazelwood, MO) at a rate of 4.0 mL/s via an 18- or 20-gauge cannula in

an antecubital vein. Triple contrast CT with oral, IV, and rectal contrast, is performed at

the request of the surgical team in selected cases of penetrating injury.

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Diagnostic methods

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Despite its limitations, imaging plays a critical role in the diagnosis of diaphragmatic

injuries. In blunt polytrauma, clinical signs are often non-specific or obscured by more
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serious life-threatened injuries. In penetrating trauma, even seemingly minor, small

penetrating wounds at the thoracoabdominal area carry increased risk of injury to the
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diaphragm. In those cases, the trajectory of the penetrating wound is key to determine

the search pattern of possible diaphragmatic injury [2]. Given the potential life-threating
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complications of a missed diagnosis, signs of diaphragmatic injury should be carefully

searched on the performed imaging studies [1, 9].

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Chest radiograph
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As an integral part of the ACLS protocol, chest radiography is almost always the first

imaging study to be obtained on a trauma patient. Initial portable chest radiographs

performed at presentation raise suspicion in only 27–68% of cases of left

hemidiaphragmatic injury and in 17–33% in right diaphragmatic injury [10, 11].

Asymmetric elevation of the hemidiaphragm, obscuration of the diaphragmatic shadow,

and irregular diaphragmatic contour are among the non-specific signs described on

chest radiography in patients with diaphragmatic injury. However, these signs have low

specificity and are frequently seen in other traumatic conditions such as pneumothorax,

hemothorax and pulmonary contusions. Among the radiographic signs, herniation of

abdominal organs into the thoracic cavity and supradiaphragmatic position of the

nasogastric tube tip remain the most specific findings.

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Thoracoscopy and Laparoscopy

In the absence of a diaphragmatic hernia, imaging has an otherwise low diagnostic

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sensitivity for diaphragmatic injury. Therefore, some centers advocate minimally
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invasive surgical techniques for diagnosis in high risk patients eligible for non-operative

management. In cases of penetrating trauma to the left thoracoabdominal region, the

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use of laparoscopy or thoracoscopy has been advocated [2]. However, these invasive

techniques are not infallible with numerous reports of missed PDIs at laparoscopy and
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laparotomy [12].

A level 1 trauma center study using laparoscopy and thoracoscopy as a diagnostic tool
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in patients with penetrating injury to the left lower thorax and/or upper quadrant showed

a 42% incidence of diaphragmatic injury [13]. Among patients with diaphragmatic injury,
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31% had no abdominal tenderness, 40% had a normal chest radiograph, and 49% had

an associated hemopneumothorax [13]. Approximately one quarter of the patients

undergoing laparoscopy (26%) had occult diaphragm injuries [13]. The authors

advocate the use of minimally invasive diagnostic laparoscopy to assess the integrity of
the diaphragm in patients with penetrating trauma in the left thoracoabdominal region

and concurrently perform any necessary repair [13]. Another group evaluated a similar

cohort of penetrating injury patients using video-assisted thoracoscopy and concluded

that the method is as safe and accurate as exploratory celiotomy for the detection of

diaphragmatic injuries [14].

Multidetector CT (MDCT)

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Multidetector CT (MDCT) remains the first-line imaging modality for screening

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hemodynamically stable victims of penetrating and blunt trauma and has better

accuracy than chest radiographs in detecting traumatic diaphragmatic injury [3, 4, 15].

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Recent literature has highlighted improved diagnostic accuracy using MDCT by
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employing thinner slices and multiplanar reformats in conventional and oblique planes

[8, 16, 17]. Advanced post-processing techniques, such as CT tractography, further

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increases the accuracy of MDCT [8]. Such studies have shown sensitivities of 73–100

% and overall accuracies of 70–89 % of MDCT. As expected, MDCT has higher

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sensitivity to detect diaphragmatic rupture rather than smaller non-herniating

diaphragmatic defects. It also has greater sensitivity to detect injuries of the left
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hemidiaphragm due to the liver obscuring the diaphragm [3, 4, 6, 8].

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Imaging findings in Blunt Diaphragmatic trauma:

MDCT signs

“Collar” sign
The collar sign is a waist-like constriction at the level of the diaphragmatic defect around

the herniated contents, which usually contain bowel or intra-abdominal fat (Figure 1) [1,

6]. The collar sign typically involves the stomach on the left side. The reported

sensitivity of this sign is variable depending on the side effected (36–85% for left-sided

and 17–50% and right-sided injury), with an overall specificity ranging from 80 to 100%

[1].

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“Dependent Viscera” sign

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While in the supine position, the posterior aspect of the diaphragm supports the

abdominal organs, separating them from the posterior chest wall. In the presence of a

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diaphragmatic injury, the intraabdominal viscera lose the posterior support, and lie
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directly against the posterior ribcage (Figure 1) [6]. The dependent viscera sign

presents on the right side when the upper third of the liver has contact with the posterior
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chest wall without interposed pulmonary parenchyma and on the left when the stomach,

bowel or spleen lie against the posterior ribs [1].

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“Focal Defect” sign

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A focal diaphragmatic defect represents the most commonly encountered MDCT sign of

diaphragmatic injury in blunt trauma, with sensitivity values up to 95.7% (Figure 2) [1,
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18]. The defect is easier to identify on multiplanar reconstructions performed

perpendicular to the tear rather than on traditional axial images. It is often delineated by

slightly thickened borders because of edema, intramuscular hematoma and muscle

retraction. Physiological diaphragmatic defects are a common pitfall, which may be

observed in up to 11% of healthy population, with a prevalence that increases with age

[1].

“Dangling” Diaphragm sign

The dangling diaphragm sign is commonly seen with large diaphragmatic injuries where

the free defect edges are retracted, curling inward toward the abdomen and away from

the posterior thoracic wall and giving the appearance of a “dangling” segment of loose

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diaphragm (Figure 2). The sensitivity and specificity is 54% and 98% respectively [1].

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“Hump sign and Band sign”

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They are considered right sided variations of “collar sign” in the setting of herniation of
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the liver through the right hemidiaphragm defect. The “hump sign”, with a reported

sensitivity of 83%, represents the abnormal focal bulge of the right hemidiaphragm
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related to superior migration of the liver parenchyma through the site of injury (Figure 3).

The “band sign” has lower sensitivity at 33% and represents the ring of low attenuation
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around the hepatic tissue at the diaphragmatic tear. The band is thought to be due to

decreased perfusion from constriction at the narrow herniation site [1, 9, 18]. The
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“hump and band” signs can be easily detected using high quality sagittal and coronal

multiplanar reformations [9, 27].

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Imaging findings in Penetrating Injury

Injuries related to penetrating trauma are usually between 1–4 cm with 85% of cases

being less than 2cm. [10]. Therefore, the most useful signs in identifying PDI in the
acute setting are those that demonstrate or imply a simple breach- these include direct

visualization of diaphragmatic discontinuity, a transdiaphragmatic trajectory, and

‘contiguous injury on both sides of the diaphragm” in patients with single entry wounds

(Figures 4 and 5) [8, 16, 19]. When trajectory is not evident, the presence of any

combination of hemoperitoneum, hemothorax, air, bullet fragments, or hematoma on

both sides of the diaphragm is an indirect finding indicating PDI in patient with a single

penetrating wound. Unfortunately, multiple penetrating injuries are extremely frequent in

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practice. The placement of radiopaque markers on patient’s skin surface at the

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entrance and exit wounds by the trauma surgeons before the imaging acquisition helps

the radiologist extrapolate the trajectory of the penetrating injury, particularly in difficult

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and subtle cases. In our institution, the team routinely places “paper clips” to identify the
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entry points of penetrating trauma before the radiographs and CT scan images [20].

Herniation related signs are more frequently appreciated with the large defects seen
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with blunt diaphragmatic rupture. Diaphragmatic defects seen in PDI are typically

smaller and may result in subtle herniations usually containing only small amount of fat.
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Diagnostic Pitfalls
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There are many potential confounders in the MDCT interpretation of diaphragmatic

injuries. Awareness of these pitfalls should help to further improve interpretive

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accuracy. Imaging pitfalls can be divided between patient’s related factors or those

inherent to the mechanism of injury.

Congenital and Acquired Defects

First, it is important to recognize several anatomic variants, both congenital and

acquired, that may be confused with diaphragmatic injury (Figure 6). Asymptomatic

congenital diaphragmatic hernias are commonly seen on cross sectional imaging.

Bochdalek hernias are the most common type, located posterolaterally and often on the

left side. The less common Morgagni hernias are located anteriorly and medially [15,

21]. Most are detected incidentally and are small, containing only fat although larger

ones may contain abdominal viscera. If there is lack of associated signs of trauma, and

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the herniated fat is uniform density without stranding, a hernia in these classic locations

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can be confidently recognized as congenital and not traumatic.

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Diaphragmatic eventrations are areas of congenital thinning of the muscle with

abnormal relaxation and elevation, resulting in a focal bulge [21]; usually this involves
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only a segment of the diaphragm and are frequently recognized on chest radiography.
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Acquired diaphragmatic defects known as fenestrations or pores are well reported in the

literature [22]. These small diaphragmatic discontinuities are most frequently seen

posteriorly or at the crura and can increase with patient age, ranging from less than 1
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mm to 1 cm. These allow for communication between the thorax and abdomen [15].
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Abnormal thickening of the diaphragm or crura has been reported as a sign of

diaphragmatic injury including partial rupture with hematoma [15]. But the radiologist
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needs to keep in mind that there is also considerable variability in diaphragmatic

thickness, depending on age, habitus, and respiration [15, 23] as well as anatomic

variation related to the attachment of diaphragmatic slips, muscle bundles and the

arcuate ligaments that can contribute to focal thickening or nodularity of the diaphragm,

that should not be confused for injury or pathology [21].

Mechanistic Pitfalls

Mechanism specific pitfalls are seen with penetrating DI. Penetrating DI presents

unique challenges as the defect/injury is much smaller than is typically seen with blunt

trauma [13, 15, 24]. These small injures are often missed at presentation because the

little separation of muscle fibers and lack of herniated abdominal contents [25] makes

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the injury difficult to detect. Diagnostic difficulties arise when the trajectory of an

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individual injury may not be linear. An injury trajectory may be subtle in the case of stab

wounds. Frequent causes of distortion of the trajectory include inconsistency between

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the phase of respiration during scanning, and at the time of the traumatic event, as well

as arm raising during the scan. However, accurate diagnosis can usually be made by
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carefully evaluating the trajectory on thin axial slices and standard/oblique multiplanar
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reformations. Ricochet effect of bullets and multiple GSWs can hamper determination if

a single injury trajectory crossed the diaphragm. In addition, in the setting of multiple

penetrating insults, the contiguous injury sign loses specificity as the injuries may have
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been caused by two separate wounds.

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Delayed Herniation

Untreated diaphragmatic injury are associated with high morbidity and mortality
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stressing the importance of making a timely diagnosis [15, 26]. Small initial

diaphragmatic defects may enlarge over time which can lead to herniation and

entrapment of abdominal organs. Up to 30-60% of diaphragmatic ruptures may have a

delayed clinical presentation, with absent or intermittent symptoms due to transient

herniation [25, 27]. Delayed herniation through missed injuries may occur anywhere

from a few days to many years after injury [8] however, the majority occur within 3 years

of initial injury [15].

The morbidity and mortality of delayed diagnosis comes from incarceration or eventual

strangulation of the herniated contents. The mortality rate of delayed diagnosis of

traumatic diagnostic injury after a stab wound has been reported as high as 36% [28].

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Patients can present with nonspecific symptoms including chest or abdominal pain,

dyspnea, tachypnea, or cough [27]. In addition to hollow viscus incarceration and

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strangulation, other complications of diaphragmatic injury include respiratory

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insufficiency, pneumonia, pleural collections, and intrathoracic splenosis [15].
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Conclusion
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The diagnostic performance of MDCT for the diagnosis of diaphragmatic injuries has

significantly improved over the years due to the increased use of isotropic data sets,
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thinner slices, multiplanar reformats and tractography [6, 9]. However, despite the

technological imaging advancements, diaphragmatic injuries remain a difficult diagnosis

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for trauma surgeons and radiologists. Small traumatic diaphragmatic tears in the

absence of complete rupture or organ herniation are still significantly underreported,

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particularly in cases of penetrating wounds. The high incidence of concomitant life-

threating injuries in the polytrauma patient can also distract the radiologist for presence

of diaphragmatic injuries. Furthermore, radiologists should routinely screen the MDCT

images for diaphragmatic injuries in most thoracoabdominal penetrating and severe

blunt trauma patients. Knowledge of the diaphragmatic injury differences between blunt

and penetrating mechanisms, epidemiology and respective imaging signs are primordial

for improving accuracy and decreasing misdiagnosis.

CRediT Author Statement

Fabio M Paes – Conceptualization, Resources, Investigation, Writing - Original Draft,

Writing - Review & Editing, Visualization

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Anthony M Durso - Resources, Investigation, Writing - Original Draft,

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Gary Danton - Resources, Investigation, Writing - Original Draft,

Ivan Castellon - Resources, Visualization

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Felipe Munera – Conceptualization, Supervision, Writing - Original Draft, Writing -
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Review & Editing

Conflict of Interest Statement

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The authors and authors’ institution have no conflict of interest, including

financial or personal relationships that inappropriately influence his or her

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actions or opinions.

Disclosure of conflict of interest: None of the authors have disclosed relevant

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relationship.
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Pictures

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Figure 1 - Collar sign and dependent viscera sign. 76-year-old female in motor
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vehicle crash. Coronal (a), and sagittal (b) MPR reconstructions show a left

diaphragmatic defect (white arrows) with herniation of the majority of the stomach into
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the thorax. On coronal reconstructions, there is constriction of the stomach at the

diaphragmatic tear with a “collar sign”. On sagittal MPR reconstruction, the stomach in
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the posterior thorax is in contact with the posterior chest wall (white arrowhead)

consistent with “dependent viscera sign”.

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Figure 2 - Dangling diaphragm and focal defect. Patient after parachuting accident

with multiple traumatic injuries taken to directly to surgery. Post-operative axial CT

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image (a) shows a diaphragmatic rupture with retraction of the free edge –dangling

diaphragm sign (white arrow). Also, visible, is pneumoperitoneum and surgical packing
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material from surgery. The large focal defect of the diaphragm is best seen on coronal
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reformation (b) situated between the thickened and retracted diaphragmatic crus

medially (white arrowhead) and the lateral edge of the diaphragmatic tear (white arrow).
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The stomach is seen herniating superiorly into the thorax.

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Figure 3 - Hump sign. 17-year-old male involved on motor vehicle crash. Initial chest
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radiograph (a) shows a pneumothorax and abnormal bulge of the of the superior liver

margin - the “hump sign” (white arrow). Exploratory laparotomy confirmed right
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diaphragmatic injury in addition to intrabdominal hemorrhage (not shown). Hemostasis

was achieved but the diaphragmatic tear was not repaired at that time. Immediate post-
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operative coronal CT reconstruction (b) re-demonstrates abnormal bulge of the superior

liver margin (white arrow).

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Figure 4 - Penetrating diaphragmatic injury. 21-year-old male with left

thoracoabdominal gunshot wound. Coronal (a) and Sagittal (b) CT images show a
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small diaphragmatic tear (arrow) with herniation of the splenic flexure of the colon.
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Associated injuries also include hemothorax, pulmonary contusions, and subcutaneous

emphysema.
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Figure 5 - Penetrating diaphragmatic injury. 45-year-old male with a stab wound to

the anterior chest wall. Axial CT image (a) shows a subtle defect (white arrow) at the

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anterior diaphragm and a small hemothorax. Sagittal MPR reformation (b) better shows

the diaphragmatic tear (white arrow) and an associated small liver laceration (black
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arrow). The presence of contiguous injury on both sides of the diaphragm is essentially
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diagnostic of diaphragmatic injury in this patient with a single-entry wound.

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Figure 6 - Location of common pitfalls. 3D-volume rendering of a normal diaphragm
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demonstrating common locations of the non-traumatic congenital or acquired

diaphragmatic defects: Bochdalek hernias (white arrow), Morgani hernias (white

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arrowhead), discontinuity between the crus and lateral arcuate ligament (black arrow),

fenestrations (black arrowhead) and eventrations (star).

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