Diaphragmatic Trauma

Description

• Penetrating injury:
  • Violation of the diaphragm by penetrating object (most commonly stab and gunshot wounds)
  • May involve any portion of diaphragm
  • Smaller defect compared with blunt injuries (more likely to be missed)
• Blunt injury:
  • Increased intra-abdominal or intrathoracic pressure is transmitted to diaphragm, causing rupture
  • Injuries are more commonly left-sided:
    • Left hemidiaphragm has posterolateral embryologic point of weakness
    • Right hemidiaphragm is protected by liver
    • Injuries are larger than with penetrating injury (frequently between 5–15 cm in length)
• Diaphragmatic defects do not heal spontaneously because of pleuroperitoneal pressure gradient:
  • May exceed 100 cm H₂O during maximal respiratory effort
  • Promotes herniation of abdominal contents through tear in diaphragm

Epidemiology

Incidence
Uncommon; <1% of all traumatic injuries

Etiology

• Lateral torso impact is 3 times more likely to result in ipsilateral diaphragmatic rupture than frontal impact
• Suspect diaphragmatic injury:
  • Penetrating trauma to thoracoabdominal area
  • Injuries that cross plane of the diaphragm, which can extend up to the fourth rib