The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Jacob Leedekerken, MD, Chelsea Wilson, MD, and Travis Barlock, MD. It is has special guest editor: Kyle Cunningham, MD

1. Diaphragm Injury Case Studies
Jacob Leedekerken, MD; Chelsea Wilson, MD;
Travis Barlock, MD
Departments of Emergency Medicine & Surgery
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD & Kyle Cunningham, MD Faculty Editors
The Chest X-Ray Mastery Project

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: Diaphragm Injury.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. It’s All About The Anatomy!

6. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

7. Injury Demographics
Maryland Shock Trauma Case Series 1995-2009, [n=773]:
Penetrating 73%
Blunt 27%
Left 57%
Right 40%
Bilateral 3%
Mortality: Left 17%
Mortality: Right 26%
*Overall Mortality 21%
Factors Associated With
Increased Mortality
• Age
• Injury severity score
• Associated cardiac injury
• Right diaphragm injury
• Operative intervention
Zarour A. JT&ACS 2013; 74:1391.

8. Injury Demographics
National Trauma Data Bank Review:
• Diaphragm injuries are rare, incidence: 0.46%
• Mechanism: 67% penetrating and 33% blunt
Penetrating Blunt
 Gunshot wounds 67%  Motor vehicle crash 63%
 Stab wounds 33%  Bicycle/pedestrian stuck 10%
Mortality 9% Mortality 20%
Fair KA. J Trauma 2015; 209:864-868.

9. Penetrating Injury
The diaphragm is at risk with any
penetrating wound occurring
between:
Williams, M. (2019). Recognition and management of diaphragmatic injuries in adults. In T.W. Post, E. Bulger, & K. Collins (Eds.), UptoDate. Available
from https://www.uptodate.com/contents/recognition-and-management-of-diaphragmatic-injury-in-adults#H19492683
T4 and T8: Chest/Abdomen
T4 and T12: Back

10. Associated Injuries In >50% Of Cases
Williams, M. (2019). Recognition and management of diaphragmatic injuries in adults. In T.W. Post, E. Bulger, & K. Collins (Eds.), UptoDate. Available
from https://www.uptodate.com/contents/recognition-and-management-of-diaphragmatic-injury-in-adults#H19492683

11. Radiologic Findings
Chest X-ray signs:
• Indistinct and/or elevated
hemidiaphragm1
• Basilar atelectasis
• Abdominal organs in the thorax
• Abnormal nasogastric tube
position
1Be cautious not to mistake a diaphragm
injury for a hemothorax!
CT scan signs:
• Discontinuous diaphragm sign
• Dependent viscera, dangling
diaphragm, and collar signs (blunt)
• Organ herniation into thorax
• Diaphragm thickening
• Contiguous injury (penetrating)
Bonatti M, Lombardo F, Vezzali N, Zamboni GA, Bonatti G. Blunt diaphragmatic lesions: Imaging findings and pitfalls. World J Radiol 2016; 8(10): 819-828.
Iochum, S., Ludig, T., Walter, F., Sebbag, H., Grosdidier, G., & Blum, A. G. (2002). Imaging of Diaphragmatic Injury: A Diagnostic Challenge? RadioGraphics,
22(suppl_1). doi: 10.1148/radiographics.22.suppl_1.g02oc14s103.

14. Discontinuous Diaphragm Sign
The discontinuous diaphragm sign is present if there is visualization of direct
discontinuity of the diaphragm, along with segmental non-visualization.

15. Dangling Diaphragm Sign
The dangling diaphragm sign is present if the free edge of the torn diaphragm is
visible, curled inward away from the chest wall towards the central abdomen.

16. Collar Sign
The collar sign, also called
the hourglass sign refers to a
waist-like or collar-like
appearance of herniated organs
at the level of the diaphragm.

17. Intrathoracic Herniation Of Viscera
Intrathoracic herniation of
viscera is present if
intrabdominal organs are
visible within the thoracic
cavity through the defect in
the diaphragm.

18. Dependent Viscera Sign
The dependent viscera sign is present if the liver abuts the posterior ribs on the
right, and/or if bowel abuts the ribs, or lays posterior to the spleen on the left.

19. Contiguous Injury Across The Diaphragm
Contiguous injury across diaphragm implying transdiaphragmatic penetration,
is an indirect sign of (typically penetrating) diaphragmatic injury.
Hemothorax &
Lung ContusionLiver
Laceration

20. Thickening Of The Diaphragm
Thickening of the diaphragm may be present at the site of injury with or
without retraction of the edges.

24. Carolinas Medical Center Case Studies

25. Case #1
61-Year-Old In A
High Speed MVC
Complains Of
Chest And
Abdominal Pain.
While In The ED
She Develops
Worsening
Respiratory
Distress
Requiring
Intubation And
Transfer To CMC.

26. Case #1
61-Year-Old In A
High Speed MVC
Complains Of
Chest And
Abdominal Pain.
While In The ED
She Develops
Worsening
Respiratory
Distress
Requiring
Intubation And
Transfer To CMC.
Ruptured Diaphragm
Elevated
Hemidiaphragm

27. 61-Year-Old With A Ruptured Left Hemidiaphragm
CT Scout Film
Elevated
Hemidiaphragm

28. 61-Year-Old With A Ruptured Left Hemidiaphragm
Viscera Herniated Into The Chest

29. 61-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: K. Cunningham, MD

30. 61-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: K. Cunningham, MD

31. 61-Year-Old With A Ruptured Left Hemidiaphragm
Post-Operative CXR

32. Case #2
17-Year-Old In A
High Speed MVC
Complains Of
Abdominal Pain.

33. Case #2
17-Year-Old In A
High Speed MVC
Complains Of
Abdominal Pain.
Elevated
Hemidiaphragm

34. Ruptured Diaphragm
Viscera Herniated
Into The Chest
Case #2
17-Year-Old In A
High Speed MVC
Complains Of
Abdominal Pain.

35. Case #3
57-Year-Old In A
High Speed At An
Outside ED.

36. Case #3
57-Year-Old In A
High Speed At An
Outside ED.
Chest Tube
Placed
Initial Interpretation: Left Hemothorax

37. Ruptured Diaphragm
Chest Tube
In The Abdomen
57-Year Old In A High Speed MVC – Now At CMC.

38. Ruptured Diaphragm With Chest Tube Next To The Stomach
57-Year Old In A High Speed MVC – Now At CMC.

39. Case #4
45-Year-Old
Male
Involved In A
Roll-Over Car
Crash.
Intubated In
The Field.

40. Elevated
Hemidiaphragm
Case #4
45-Year-Old
Male
Involved In A
Roll-Over Car
Crash.
Intubated In
The Field.

41. Ruptured Diaphragm
Viscera Herniated
Into The Chest
45-Year-Old MVC

42. Case #4
45-Year-Old Male
With Rupture Of
The Left
Hemidiaphragm.
Chest X-Ray After Repair

43. Case #5
60-Year Old In
A Motor
Vehicle Crash.

44. The Left
Hemidiaphragm
Is Indistinct.
Case #5
60-Year Old In
A Motor
Vehicle Crash.

45. 60-Year Old In A Motor Vehicle Crash.
Ruptured Diaphragm
Collar
Sign

46. Case #6
46-Year Old In
A Motor
Vehicle Crash.
Elevated
Hemidiaphragm
Disarticulated
Rib

47. Case #6
46-Year Old In
A Motor
Vehicle Crash.
Spleen Herniated
Into The Thorax
Viscera Herniated
Through The Chest
Wall

48. Case #6
46-Year Old In
A Motor
Vehicle Crash.
The Patient Also Has A Tear
Of The Descending Aorta

49. 46-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: G. Sachdev, MD

50. 46-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: G. Sachdev, MD

51. 46-Year-Old With A Ruptured Left Hemidiaphragm - Repaired
*****
Courtesy: G. Sachdev, MD

52. Case #6
46-Year Old In
A Motor
Vehicle Crash.
Chest X-Ray After Repair And Aortic Endograph Placement

54. SUMMARY Of 2018 EAST Practice Management Guidelines
#1 In stable patients with left thoracoabdominal stab wounds, laparoscopy
is recommended rather than CT imaging to decrease the incidence of
missed diaphragm injuries.
#2 In stable patients with confirmed or suspected penetrating injuries of
the right diaphragm, non-operative management is recommended over
operative management.
#3 In stable patients with acute diaphragm injuries, the abdominal rather
than the thoracic approach is preferred for injury repair.
#4 In patients with acute penetrating diaphragm injuries without concerns
for other intraabdominal injuries, laparoscopic repair is recommended
over open repair.

56. If you have interesting cases of Diaphragm Injury, we invite you to send a set
of digital PDF Images and a brief descriptive clinical history to:
michael.gibbs@atriumhealth.org
Your De-Identified case(s) will be posted on our education website and you
and your institution will be recognized!