This document discusses diaphragmatic injury, including its etiology, associated injuries, signs and symptoms, diagnostic approaches, and management. The majority of diaphragmatic injuries are caused by penetrating trauma, most commonly stab wounds or gunshots. Left-sided injuries are more often associated with blunt trauma from high pressure to the chest or abdomen. Common associated injuries include damage to the spleen, ribs, liver, lungs, head, pelvis, and bowels. Diagnosis can be made through chest x-rays, ultrasound, CT scans, or laparoscopy. Surgical repair is usually required to suture tear sizes over 2 cm. Complications include herniation of abdominal organs into the chest and pulmonary issues if left

1. DIAPHRAGMATIC INJURY
Department of surgery
Songkhla hospital

2. CONTENT
 Anatomy
 Etiology
 Mechanism of injury
 Associated injury
 Sign and symptom
 Diagnostic approach
 Complication of Diaphragmatic injury
 Management

4. ETIOLOGY
 DI 0.63% National Trauma Data Bank (NTDB)
 65 % Penetrating injury
 35 % Blunt injury

5. 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 %

6. ASSOCIATED INJURY
 Rt.diaphragmatic injury
 Associated intraabdominal injury ~100%
 Lt.diaphargmatic hernia injury
 Associated intraabdominal injury ~77%
 Descending aorta injury 5-8%

7. 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
 Blunt force to abdomen or chest elevate
pressure > +150-200 cmH2O
 Wound size 5-10 cm.

8. 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

9. 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

10. WORK UP
 Chest radiography
 Ultrasound
 Computer tomography
 Magnetic resonance imagine
 Laparoscopy
 Explore-Laparotomy

11. 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

12. CHEST RADIOGRAPHY
 Collar sign

13. CHEST RADIOGRAPHY

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

15. 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.

16. 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

17. CT
 Discontinuity of the diaphragm

18. CT
 Herniation of the abdominal contents into the
chest

19. CT
 Viscera (liver, stomach) are in direct contact
with the posterior ribs

20. MRI
 High suspicious with others negative studied
 Time-consuming
 Hemodynamic patient

21. MRI
CT MRI

22. LAPAROSCOPY
 High sensitivity and specificity especially in
penetrating injury
 Have benefit in case that no indication for
immediated surgery

23. EXPLORE-LAPAROTOMY
 Gold standard
 Unstable hemodynamic patient

24. 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

25. 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

26. 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

27. THANK YOU