Traumatic Diaphragmatic Rupture

A 30-year-old female, after a motor vehicle collision, presented with chest pain, abdominal pain, shortness of breath, and rib fractures. Diagnosis? • Xray of the Week

Figure 1. Coronal and axial CT Scan. Diagnosis?

Figure 2. CT scan of traumatic left hemi-diaphragmatic rupture. (A) Coronal CT images demonstrate abdominal viscera herniating into the left hemithorax (yellow arrow pointing to colon), consistent with traumatic disruption of the left hemidiaphragm. (B) Axial CT image also demonstrates abdominal organs including spleen (red arrow) in the chest.

Figure 3. Prior CT examination. Coronal CT image obtained one year earlier demonstrates the pre-trauma thoracoabdominal anatomy in the same patient without the left-sided intrathoracic visceral herniation seen on the current examination. Normal left hemidiaphragm (yellow arrow).

Epidemiology

Traumatic diaphragmatic rupture is uncommon, occurring in approximately 0.5% of all trauma patients and around 1–2% of patients with blunt trauma [1]. Motor vehicle collisions are a major cause of blunt diaphragmatic rupture. Left-sided injuries predominate, accounting for approximately 65–80% of cases, while right-sided and bilateral ruptures are less frequent. Diaphragmatic rupture commonly occurs in the setting of high-energy thoracoabdominal trauma and is frequently accompanied by other traumatic injuries [1,2].

Clinical Findings

Clinical presentation of traumatic diaphragmatic rupture is variable and may be obscured by associated thoracic or abdominal injuries. Patients may present with chest or abdominal pain, dyspnea, tachypnea, or respiratory distress. Physical examination may demonstrate decreased breath sounds or, when abdominal viscera have herniated into the thorax, bowel sounds within the chest. Some injuries may initially be clinically occult, contributing to delayed diagnosis [1,2].

In this case, the 30-year-old woman presented following a motor vehicle collision with chest pain, abdominal pain, and shortness of breath; associated rib fractures were also documented.

Pathology

Traumatic diaphragmatic rupture results from disruption of the musculotendinous diaphragm following blunt or penetrating thoracoabdominal trauma. In blunt trauma, sudden elevation of intra-abdominal pressure and shearing forces can produce diaphragmatic tears, which commonly involve the posterolateral diaphragm [2]. The resulting defect may permit abdominal viscera to herniate into the thoracic cavity because of the pressure gradient between the abdomen and chest. If unrecognized, progressive herniation may lead to incarceration or strangulation of herniated viscera.

Classification

Traumatic diaphragmatic injuries are graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scale. Grade I represents diaphragmatic contusion; Grade II, a laceration <2 cm; Grade III, a laceration 2–10 cm; Grade IV, a laceration >10 cm with tissue loss <25 cm²; and Grade V, a laceration with tissue loss >25 cm². Bilateral injuries are advanced by one grade up to Grade III [3]. This classification describes the anatomical severity of diaphragmatic injury.

Radiographic Features

Chest radiography may demonstrate an elevated or irregular hemidiaphragm, intrathoracic abdominal viscera, abnormal diaphragmatic contour, or associated pleural and pulmonary abnormalities; however, findings may be subtle or nonspecific [4]. Multidetector CT is the principal imaging modality for evaluating suspected traumatic diaphragmatic injury [5]. Direct CT findings include focal diaphragmatic discontinuity and the dangling diaphragm sign, representing inward curling of the torn diaphragmatic edge [6]. Indirect findings include intrathoracic herniation of abdominal viscera, the collar sign from waist-like constriction of herniated viscera at the defect, and the dependent viscera sign, in which herniated abdominal organs lie against the posterior thoracic wall [7]. Coronal and sagittal multiplanar reformations may facilitate identification of diaphragmatic defects and visceral herniation. Associated thoracoabdominal injuries, including rib fractures, may also be identified.

Treatment and Prognosis

Traumatic diaphragmatic rupture requires surgical repair once the patient's condition permits. Herniated abdominal viscera are reduced and the diaphragmatic defect is usually closed primarily with sutures; mesh may be required for larger defects that cannot be closed without tension [8]. The operative approach may be abdominal, thoracic, or minimally invasive depending on clinical stability, associated injuries, and timing of presentation [1,8]. Prognosis is largely determined by the severity of associated traumatic injuries rather than the diaphragmatic defect itself. Delayed or missed diagnosis may result in visceral incarceration, strangulation, or respiratory compromise [8].

Conclusion

Traumatic diaphragmatic rupture is an uncommon but important complication of thoracoabdominal trauma that may be difficult to recognize clinically. Awareness of characteristic imaging findings, particularly on multidetector CT, is essential for prompt diagnosis and appropriate management, helping to reduce complications associated with delayed or missed injury.

References

1. Furák J, Athanassiadi K. Diaphragm and transdiaphragmatic injuries. J Thorac Dis. 2019;11(Suppl 2):S152-S157. doi:https://doi.org/10.21037/jtd.2018.10.76

2. Petrone P, Asensio JA, Marini CP. Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Curr Probl Surg. 2017;54(1):11-32. doi:https://doi.org/10.1067/j.cpsurg.2016.11.001

3. Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV: thoracic vascular, lung, cardiac, and diaphragm. J Trauma. 1994;36(3):299-300. doi:https://doi.org/10.1097/00005373-199403000-00002

4. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012;32(2):477-498. doi:https://doi.org/10.1148/rg.322115082

5. Nchimi A, Szapiro D, Ghaye B, et al. Helical CT of blunt diaphragmatic rupture. AJR Am J Roentgenol. 2005;184(1):24-30. doi:https://doi.org/10.2214/ajr.184.1.01840024

6. Desser TS, Edwards B, Hunt S, Rosenberg J, Purtill MA, Jeffrey RB. The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture. Emerg Radiol. 2010;17(1):37-44. doi:https://doi.org/10.1007/s10140-009-0819-5

7. Bergin D, Ennis R, Keogh C, Fenlon HM, Murray JG. The “dependent viscera” sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol. 2001;177(5):1137-1140. doi:https://doi.org/10.2214/ajr.177.5.1771137

8. Giuffrida M, Perrone G, Abu-Zidan F, et al. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg. 2023;18(1):43. doi:https://doi.org/10.1186/s13017-023-00510-x

Umaiza Ihsan, MD, is a medical graduate of King Edward Medical University,

Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three-

month rotation in Radiology, which further strengthened her interest in diagnostic

imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision-making, and is actively interested in clinical research, with experience in systematic reviews and medical research.

Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.

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