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Imaging of Diaphragmatic rupture
The diaphragm attaches anteriorly and laterally to the inferior sternum, xiphoid process, lower ribs, and costal cartilage. Posterior attachments include the crura and arcuate ligaments connecting to the lumbar vertebrae. Diaphragmatic rupture often results from blunt trauma, presenting with dyspnea, chest pain, and herniated abdominal organs into the thorax seen on imaging as dependent viscera or the collar sign. Delayed presentations can lead to bowel strangulation. CT is the most sensitive imaging method to detect discontinuity of the hemidiaphragm and intrathoracic herniation of abdominal contents. Surgical repair is usually required to correct diaph
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Imaging of Diaphragmatic rupture
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- 2. Drawing (view frombelow) shows the large central tendon, which is formed by the transverse septum.
- 3. Anterior and lateralattachments • Inferior sternum, xiphoid process, lower six ribs, and costal cartilage. Posterior attachments • The two diaphragmatic crura • The medial arcuate ligaments • The lateral arcuate ligaments upper lumbar vertebral bodies b/n the L1 or L2 VB and the TPs of L1. TPs of T12 laterally to midportion of the 12th ribs.
- 4. DIAPHRAGMATIC RUPTURE • Post-traumaticlaceration of hemidiaphragm, frequently resulting in herniation of abdominal viscera into thorax. Etiology: • Trauma (M.C) -Blunt trauma more common than penetrating trauma. • Less commonly idiopathic or related to previous surgery. Location: • Occur more on the left. • Clinical manifestation (visceral herniation) much more common on left side (70-90%).
- 6. Morphology: • Tears areusually >10 cm in length, are radially orientated and occur at the weakest part of the diaphragm, the musculotendinous junction in a posterolateral location. • Prevalence of visceral herniation increases with larger tears
- 7. • Presentation: • Acute •Multiple associated injuries- pelvic fractures, splenic injuries and renal injuries • Symptoms may be nonspecific and include dyspnea, chest pain, shoulder pain, and cyanosis • Diagnosis delayed when • Often other more compelling injuries such as aortic laceration • Intubated patient on positive pressure may prevent herniation • Clinical diagnosis of acute diaphragm injury can be challenging. Consequently, a high index of suspicion is required. • Delayed/Obstructive • In delayed presentation often Strangulation of bowel occurs
- 8. • Radiographic Findings•Chest radiography usually abnormal but often nonspecific • Specific signs: 1. Air-filled viscus in hemithorax with or without focal constriction of the viscus at the site of the tear (collar sign). 2. Tip of NG tube in hemithorax • Abnormal diaphragmatic contour and changes in shape with change in position. • Elevated diaphragm > 7 cm. • Contralateral mediastinal shift. • Strangulation of bowel.
- 12. CT Findings• Morespecific 1. Direct discontinuity of the hemidiaphragm- most sensitive sign of rupture 2. Intrathoracic herniation of abdominal contents1. 2. left side - The stomach and colon right side -liver Collar sign - Visceral herniation with focal constriction of bowel or liver 3. • Hump and Band -The hump and band signs both result from herniation of the liver through a right-sided diaphragmatic rupture . Dependent viscera sign is very accurate. 1. 1. 2. Visualization of abdominal viscera against posterior chest wall. Diaphragmatic thickening, segmental absence, and combined hemothorax and hemoperitoneum are strong predictors of blunt diaphragmatic rupture
- 16. Collar Sign orHour Glass Sign
- 19. Hump and BandSign
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- 25. Thickening of theDiaphragm
- 26. MRI: MR imaging isless readily adapted to the acute trauma setting and should be reserved for patients with an uncertain CT diagnosis or delayed signs of diaphragmatic tear. USG: Bedside emergency ultrasonography can be safe and accurate. But it can be compromised by pulmonary aeration, gastric and colonic gas, subcutaneous emphysema, bandages, abdominal pain and obesity. Other Modalities• Barium gastrointestinal findings Approximation and narrowing of afferent and efferent bowel loops (pinched limbs) through the diaphragmatic defect (collar sign or kissing birds sign).
- 27. Imaging Strategy Admission supinechest radiography CXR suggestive of a diaphragmatic injury CT uncertain diagnosis after CT MRI
- 28. DIFFERENTIAL DIAGNOSIS1. Eventrationof Diaphragm • No dependent viscera sign • Hemidiaphragm should appear intact • No associated injuries • Typically seen in elderly females without a history of recent trauma 2. Diaphragm Paralysis • Paradoxical motion at fluoroscopy (sniff test) • No recent history of trauma 3. Sub-pulmonic or loculated Pleural Effusion• No abnormally positioned air-filled bowel • Crus intact 4. Paraesophageal Hernia • Tear rare at esophageal hiatus.
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Editor's Notes
- #7 Sites of injuries. Drawing shows radial (A), transverse (B), and central (C) ruptures and a peripheral detachment (D). Radial tears appear to be the most frequently found injury at surgery, whereas peripheral detachments are the least frequent.
- #10 Diaphragmatic rupture. Chest radiograph showing a left-sided diaphragmatic rupture. Bowel can be seen herniating into the left hemithorax, the mediastinum is displaced to the right and there is a nasogastric tube seen coiled within an intrathoracic stomach.
- #11 Left-sided diaphragm rupture. Admission chestradiograph shows nasogastric tube (arrow) in intrathoracic stomach (arrowheads).
- #12 Tear usually spares esophageal hiatus. So, NG tube will course normally into abdomen and then traverse into hemithorax if stomach herniated.chest radiograph shows a gas-filled viscus above the left hemidiaphragm that corresponds to the colon (C). A nasogastric tube is clearly seen in the thoracic cavity (arrow).
- #14 CTscan obtained at the level of the hepatic hilum showsa defect in the continuity of the anterolateral lefthemidiaphragm (arrows).Ccolon.(b)CT scan ofthe midthoracic region shows intrathoracic herniation of the stomach
- #15 .(c, d)Sagittal(c)and coronal(d)reformatted images show the intrathoracic herniation of the stomach more clearly
- #17 Rupture of the left hemidiaphragm following blunt trauma due to a road accident. (A) Chest radiograph reveals left mid zone contusion. (B) Axial and (C) sagittal reformatted CT images reveal a ruptured diaphragm on the left side with the stomach herniating through into the thorax. The stomach is constricted as it passes through the diaphragmatic tear—the so-called ‘collar sign’
- #18 CT scan shows a subtle sign of a right diaphragmatic tear: a focal indentation in the posterolateral aspect of the liver with a contusion (arrow).
- #19 (b) Coronal reformatted image clearly shows a waistlike constriction of the liver
- #20 Right-sided BDR in a 35-year-old man after a motor vehicle accident. (a)Coronal maximum intensity projection image from contrast-enhanced CT shows herniation of the liver dome through a diaphragmatic rupture (hump sign), with a smooth collar sign (arrows) and a linear area of subtle hypoattenuation (band sign) (arrowhead) extending across the base of the defect. (b)Axial contrast-enhanced CT image shows an area of hypoattenuation (arrowheads) in the dome of the liver, a finding that might correspond to the band visible in a.
- #21 C+ ct Left-sided BDR in a 42-year-old man after a motor vehicle accident. Axial contrast-enhanced CT scan shows a curvilinear flap extending away from the chest wall toward the center of the abdomen (dangling diaphragm sign) (arrow), a finding that represents the torn free edge of the left hemidiaphragm, the distal part of which appears thickened (thickening of the diaphragm sign). An air-filled bowel loop is seen peripheral to the diaphragm, within the pleural cavity (abdominal content peripheral to the diaphragm or lung sign) (arrowheads).
- #22 Axial c+ct stomach lying adjacent to posterior ribs
- #23 ransverse CT scan with oral and intravenous contrast material demonstrates dependent viscera sign on the left side of a 32-year-old man. The stomach (arrow), which contains food and oral contrast material, abuts the posteriorribs on the left side and is posterior to the top of the spleen (arrowhead)
- #24 ransverse CT scan with oral and intravenous contrast material demonstrates dependent viscera sign on the left side of a 40-year-old man. The colon(arrow) abuts the posterior ribs on the left side
- #25 Multiple signs of blunt diaphragm rupture.Coronal MPR CT demonstrates intrathoracic herniationof stomach (black arrow)andcolon(white arrow), gastric collar sign (curved arrow), and free edge of ruptured left hemidiaphragm (arrowhead).
- #26 Coronal contrast-enhanced reformatted CT image at the level of the spleen shows thickening of the left crus (arrow). Parts of the stomach (ST), small bowel (SB), and omental fat (F)have herniated into the thorax and directly contact the collapsed lung (L)(herniation through a defect sign, abdominal viscera abutting thoracic fluid or a thoracic organ sign).
- #27 Sonographic signs of injury include herniation of viscera through the diaphragm[47,48], diaphragm disruption, diaphragmnonvisualization [48], and absent diaphragmexcursion during the respiratory cycle