Diaphragmatic Injury

                    Diaphragmatic injury is one cause of visceral herniation into the chest. A majority of hemidiaphragmatic ruptures occur on the left side. The most common site for rupture is at the diaphragmatic dome, and the least common is at the rib muscular insertions. A number of these posttraumatic diaphragmatic ruptures are not initially apparent; herniation increases in size with time, and thus delayed imaging is necessary
                   Some of these hernias are detected only months later. Intubation appears to hinder the detection of diaphragmatic rupture. Thus an initial chest radiograph or CT detects only about half of diaphragmatic ruptures. These hernias became clinically symptomatic from days to years after trauma, and either conventional chest radiographs or upper gastrointestinal studies are diagnostic. Strangulation of intestinal content has developed, including delayed gastric perforation into the pleural cavity.
                   A rare cause of diaphragmatic rupture is cardiopulmonary resuscitation. Computed tomography detection sensitivities for diaphragmatic rupture are disappointing, especially for right hemidiaphragmatic rupture, and are of limited use; keep in mind that detection rates vary with time after trauma. Diaphragmatic crura are not thickened in patients with an injured diaphragm; coronal and sagittal reconstructions are also of limited value in detecting subtle diaphragmatic injury. Computed tomography usually does not reveal diaphragmatic discontinuity even with thin sectioning (except in the rare diaphragmatic avulsion); rather, intestinal content not confined by the diaphragm but spilling into the thorax is diagnostic of a hernia, and in the appropriate clinical setting provides indirect evidence for diaphragmatic rupture. A waistlike intestinal constriction at the site of herniation is occasionally detected if rupture is limited in scope. These traumatic hernias need to be distinguished from congenital diaphragmatic hernias and from hernias through the esophageal hiatus.
                     Ultrasonography findings in patients with diaphragmatic rupture due to blunt trauma range from diaphragmatic disruption to a nonvisualized diaphragm. Occasionally detected is a diaphragm surrounded by fluid or abdominal content herniating through a diaphragmatic defect. Preliminary reports suggest that MRI is reliable in detecting diaphragmatic injury; coronal and sagittal MRI reveal the site of a diaphragmatic tear and detect abdominal visceral herniating into the thorax, but keep in mind the limitation on early detection, as discussed previously. Scintigraphy using intraperitoneally instilled Tc-99m–macroaggregated albumin (MAA) detects a diaphragmatic rupture but is rarely necessary. Arecdotal reports describe spontaneous diaphragmatic rupture.
This is radiology images Traumatic rupture of left hemidiaphragm. A scout view localizer prior to computed tomography (CT) reveals mediastinal shift to the right, partial left lung atelectasis and an elevated stomach.
This is radiology images of the Traumatic left hemidiaphragm rupture.A: Chest radiograph reveals gas and fluid at the left lung base.B: A barium study performed through a nasogastric tube identifies part of the stomach in the chest.This study was performed several hours after that in part A, and now considerably more abdominal content has herniated into the chest.
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