The diaphragm is a dome-shaped structure of muscle and fibrous tissue that separates the thoracic cavity from the abdomen. It is pierced by a series of apertures permitting the passage of structures such as aorta, vena cava inferior, ductus thoracicus and oesophagus between the thorax and abdomen. In addition, the diaphragm is the most important muscle used for respiration: as it contracts the volume of the thoracic cavity increases and air is drawn into the lungs [1]. Injuries of the diaphragm are often associated with serious consequences because of its anatomical position and crucial function. The most common cause of blunt diaphragmatic rupture (BDR) is severe blunt trauma from motor vehicle accidents [2].

Already in 1541, Sennertus reported an instance of delayed herniation of viscera through an injured diaphragm [3]. In 1579, Paré made the first description of diaphragmatic rupture in a French artillery captain, who initially survived a gunshot wound of the abdomen, but died 8 months later of a strangulated gangrenous colon, herniated through a small diaphragmatic defect that would admit only the tip of the small finger. Using autopsies, Paré also described diaphragmatic rupture in people, who had suffered blunt trauma [4]. It was not until the end of the nineteenth century that surgical procedures for this condition were being undertaken. The first successful diaphragmatic repairs were reported by Riolfi, in 1886, in a patient with omental prolapse, and Naumann, in 1888, operated on a patient with herniated stomach into the left chest cavity [5].

Despite having been recognised early in the history of surgery, blunt traumatic diaphragm rupture was a rarely reported condition before the twentieth century. However, rapid motor vehicle accidents (MVA) have resulted in increasing numbers of severely traumatized patients with multiple injuries globally [5]. Although blunt traumatic diaphragm rupture is relatively no longer an uncommon entity, it still remains a diagnostic and therapeutic challenge to surgeons for several reasons:

1. By virtue of its location between the thorax and abdomen, the diaphragm is rarely injured in isolation in blunt trauma [1]. Consequently signs and symptoms of acute trauma to the diaphragm may often be masked by frequent presence of concomitant multi system injuries.

2. Clinical presentations vary from asymptomatic to hemodynamic instability, gastrointestinal obstruction and respiratory insufficiency [6].

3. Clinical presentation can occur instantly, within hours, or even many years later [7,8].

4. Diagnosis is complicated by the lack of evidence for the value of routine imaging modalities [9].

A delay or missed diagnosis at the time of the initial trauma may increase morbidity and mortality. To highlight and discuss some of the diagnostic and therapeutic challenges of BDR, we present a collective review of the clinical literature of 1167 patients treated at various centres from 1957 to 2014. Furthermore, we report an unusual case of a 17-year-old man who sustained an isolated left-sided diaphragmatic rupture with visceral herniation as a result of law-velocity fall (Appendix 1).

A search was conducted in PubMed database using the following search string: Traumatic diaphragm rupture and Blunt trauma. The headlines and abstracts were screened and the relevant articles were selected for full-text reviewing. The reference lists of these articles were screened as well to find additional publications. The search was conducted on 2014-11-21 and resulted in, the inclusion of 22 studies (Figure 1).

Figure 1: The selection process illustrated in a flow diagram. The headlines and abstracts were screened, and the relevant articles were chosen for fulltest reviewing.

Study selection

Inclusion criteria were:

1. Articles written in English or one of the Scandinavian languages.

2. Articles available at the homepage of “Det Kongelige Bibliotek’’ or could be ordered.

3. Articles with relevant data about blunt diaphragmatic rupture.

Exclusion criteria were:

1. Case reports. To use case reports, which mainly present only 1 or 2 patients, would have given a false picture, since deaths or poor results rarely get published.

2. Duplicate publications.

3. Missing data.

4. Main focus on penetrating trauma.

There are no reliable data to estimate the incidence of BDR except in general terms. Most of the retrospective reviews included in this paper suggest an overall incidence less than 1% of blunt thoracoabdominal trauma [7,9,11,13,29] (Table 1).

Table 1: Demography and associated injuries. ISS = injury severity score; MVA = motor vehicle accidents. CXR = chest x-ray. CXR* = diagnosis based on CXR and physical examination

BDR has been identified in 1167 patients treated at various centres from 1957 to 2014. Of these patients, 70% were male aged from 14 to 80 years with a mean age of 39.1 years. The median injury severity score (ISS) was 32.9.

Traumas caused by high-velocity motor vehicle accidents (MVA) are the most frequent cause of BDR (Figure 2). Other causes include crush injury and fall from a height [7] - unlike our reported case (Appendix 1). The exact mechanism is not completely understood, but it is hypothesized that the pattern of BDR depends partly on the direction of impact. A lateral impact results in distortion of the chest wall, which may cause shearing of the diaphragm or avulsion of its attachment. In direct frontal impact increased intraabdominal pressure may lead to the rupture [30].

Figure 2: Mechanism of Injury.

BDR occurs more often on the left side than the right, with a mean left to right ratio of approximately 3:1 (Figure 3). The greater frequency of occurrence of left-sided rupture is thought to result from a combination of the protective effect of the liver on the right side and an area of congenital embryologic weakness in the left hemidiaphragm [12]. The predominance of the left-sided BDR may also be related to the fact that it results from a laterally directed impact and most countries contributing to the medical literature have the steering wheel on the left side of the vehicles. Additionally, the predominance of the left-sided BDR may be partly due to underdiagnosis of right-sided BDR [31]. The radiologic signs are more subtle on right side: The defect in right-sided BDR may be sealed by the liver, and herniation may therefore be delayed or absent [32]. Our results show that cases of bilateral BDR are less than 3% (Figure 3) and the literatures suggest a strong association with severe trauma and high mortality [7].

Figure 3: Side of the rupture.

Grimes [33], in 1974, described the 3 clinical phases of the rupture of the diaphragm. The first or initial acute phase begins with the injury. If not diagnosed early, the second or latent phase occurs, which is asymptomatic but may evolve into gradual herniation of abdominal contents. The diagnosis may be made later because of complications of abdominal contents herniating into the thorax. The third or obstructive phase is characterized by bowel or visceral herniation, obstruction, incarceration, strangulation and possible rupture of the stomach and colon. If herniation causes significant lung compression, it can lead to tension pneumothorax [32]. Such herniation of organs may be delayed for days or years [6,7]. In agreement with our reported case (Appendix 1) the most commonly herniated organs in case of left-sided BDR are the stomach, colon and spleen. Multiple organs are often involved in herniation [16,27].

The anatomic location of the diaphragm, its close relationship to adjacent intrathoracic and intraabdominal organs, and the severity of the trauma play a major role in the fact that BDR rarely occurs in isolation [11]. Patients with BDR have associated injuries, especially in the acute clinical phase, in 95%-100% of cases [5,11-13,24]. The rates, extracted from this present review, for the most common associated injuries in BDR are demonstrated in the following graph (Figure 4).

Figure 4: Associated injuries.

Due to the extremely high incidence of associated injuries the diagnosis of BDR is frequently missed and symptoms of acute trauma to the diaphragm may often be masked in the acute phase [1].

Since chest x-rays (CXR) are widely available and routinely obtained on blunt trauma patients, it remains valuable in the acute phase for detection of BDR. According to the examined literature CXR is diagnostic for BDR in 17%-61% of the cases (Table 2).

Table 2: Preoperative diagnosis based on CXR.

Right-sided injuries of the diaphragm are more difficult to detect on CXR since the liver serves to block herniation of the abdominal contents into the right side of the chest [32]. Specific diagnostic findings of diaphragmatic rupture on CXR include intrathoracic herniation of the abdominal contents and visualisation of nasogastric tube above the diaphragm. Suggestive findings include elevation of the hemi diaphragm, irregularity of the diaphragmatic outline and contralateral shift of the mediastinum without pulmonary or intrapleural cause [16]. However, concurrent pulmonary abnormalities related to the trauma such as pleural effusion, pulmonary contusion or laceration and phrenic nerve palsy could mimic or mask the diagnosis on CXR [30].

Several studies in the present review suggest that careful physical examination of the patient together with CXR is diagnostic for BDR in 62%-72% of the cases (Table 3). Even though the clinical presentations vary the usual clinical signs in case of diaphragmatic hernia include diminished expansion of the chest wall, absent respiratory sounds and tympany/dullness on percussion [13]. Matsevych reported that the diagnosis of BDR was improved to 90% with a repeated CXR in the following 12hrs after the trauma [13]. Smithers et al. [34], who found that initial CXR was preoperatively diagnostic in 54% of 85 patients with BDR, emphasised that correct assessment of the initial CXR is the most useful tool to make the diagnosis and mentioned that up to 90% of the CXR of patients diagnosed with BDR are found to be abnormal when reviewed retrospectively.

Table 3: Preoperative diagnosis based on CXR and physical examination (CXR*).

Currently, CT scan is the cornerstone of diagnostic work-up for patients with severe blunt trauma. According to the literature in the present review CT is diagnostic for BDR in 82-100% of the cases, which is a much higher sensitivity compered to CXR (Table 4).

Table 4: Preoperative diagnosis.

However, it takes 20-30 minutes to perform a CT scan and patients need to be hemodynamically stable [6]. Some of the typical CT signs for BDR include direct visualisation of injury to diaphragm, segmental non-visualisation of the diaphragm and intrathoracic herniation of the abdominal contents [30].

To the best of our knowledge, spontaneous healing of the diaphragmatic rupture has never been reported. The normally negative pressure gradient along with continuous diaphragmatic motion, contributes to the persistence of the lesion. Because of negative intrapleural pressure, abdominal structures generally herniate into the thorax [31]. Operation is indicated whenever the diaphragmatic rupture is diagnosed, and the patient is able to sustain the surgery. The repair should be performed as soon as possible because of the increased morbidity and mortality associated with this injury. The choice of surgical approach includes thoracotomy, laparotomy or both if necessary. A laparotomy is recommended for patients’ diagnosed early allowing exploration of the intraabdominal organs for associated injuries. Thoracotomy is necessary for delayed diagnosed diaphragmatic rupture to safely separate adhesions between abdominal organs and the thoracic wall [11,27]. The diaphragm is usually sutured with non-absorbable suture, but there are currently no studies that provide evidence that it is better than absorbable suture [6].

The death rate in our study is estimated to be 21.6%. Mortality strictly related to diaphragmatic rupture is minimal. Predictors of mortality include associated injures (head injuries, chest injuries), high ISS, age, bilateral BDR and initial clinical status. Delayed diagnosis may increase mortality up to 30% [31,32].

In conclusion BDR should be suspected in every case of blunt trauma even though most of the cases were related to high-velocity impact from MVA. Young males are the usual victims indicating their more frequent involvement in MVA. A high index of clinical suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Nevertheless, proper initial resuscitation and correction of other serious injuries may be more lifesaving in patients with BDR.

Posted to weekly for physicians.

Diaphragmatic rupture due to low-energy trauma case

Traumatic Diaphragmatic rupture is a diagnostic challenge and is usually caused by severe blunt or penetrating trauma to the thorax or abdomen [9]. We report here a case of congestive Diaphragmatic rupture with displacement of the spleen, stomach and intestines to the thorax by low energy decrease trauma.

17-year-old, previously healthy man turned to the emergency room with severe diffuse abdominal pain, tachycardia, tachypnea and acute malaise. Chest X-ray (Figure 5A) and subsequent trauma CT (Figure 5B) showed a left-side Diaphragmatic rupture with the displacement of the spleen, the stomach and intestines to the thorax. In acute laparotomy organs were mobilized back into the abdomen and diaphragm was sutured.

Figure 5: (A) Preoperative chest X-ray. (B) Preoperative CT scan of the chest and abdomen. Both images show congestive diaphragmatic rupture with abdominal contents located in the left chest wall.

Upon closer examination of history, it turned out that the patient 10 days earlier stumbled coming down the staircase by which he fell a few steps down and settled on the left flank. By the fall he heard a ‘’cracking’’ and experienced immediate pain. Because of a painful, sleepless night the patient was referred by 1813 to the emergency room. After clinical examination, he was finished with painkillers over the counter medicines and diagnosis ‘’ contusion costae ‘’.

Over the following days, the patient experienced increasing malaise, sleep problems due. Increasing pain, this was described as turvise ‘‘stomach cramps’’, nausea by eating and lack of bowel movements (in the first 5 days after the fall). For more inquiries and 1813, the patient was asked to rest and take more painkillers. Eventually he turned to the emergency room with the above clinical picture.

10 weeks after the surgery the patient had pain easier genes from incisionstedet, but had largely resumed his normal daily activities.

Diaphragmatic rupture due to a blunt abdominal trauma is abnormally with an incidence of less than 1% [9]. Furthermore, Diaphragmatic rupture as a result of a decrease trauma to meet the above case is very rare, in contrast to højenergitraumer of road accidents that make up the most common etiology [9,34]. Congestive Diaphragmatic rupture are more frequent than right-sided regardless of injury mechanism, which probably can be explained by left hemi diaphragm is congenital weaker and that the liver has a protective effect on the right hemi diaphragm [1].

The diagnosis is difficult to make both clinically and radiological. Conventional chest X-ray often shows nonspecific changes and has a sensitivity of less than 40% [6]. However, it is crucial that diaphragmatic rupture are discovered and operated acute as it can lead to life-threatening acute complications and increased morbidity due to late complications such as gastrointestinal herniation and strangulation [35].

A recent Swedish study shows that CT scan with a sensitivity of over 90%, could be crucial to diagnose Diaphragmatic rupture after blunt trauma [6]. Thus, uncharacteristic and persistent symptoms even after low-energy trauma lead to additional diagnostic measures.

Traumatic rupture of the diaphragm following blunt trauma is rare. It is most commonly seen in high-velocity impact from motor vehicle accidents. However, we present a case report of a 17-year-old man who sustained an isolated left-sided diaphragmatic rupture with visceral herniation as a result of low-velocity fall.