Traumatic Traumatic Diaphragmatic Diaphragmatic

RuptureRupture

December 2009

Kapil Verma, Harvard Medical School Year IIIGillian Lieberman, MD

Beth Israel Deaconess Medical CenterHarvard Medical School

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

Background:Background: Epidemiology of Traumatic Diaphragmatic RuptureEpidemiology of Traumatic Diaphragmatic Rupture

Trauma is the 4th most common cause of death Trauma is the 4th most common cause of death in the USA and the leading cause of fatalities in in the USA and the leading cause of fatalities in those younger than 45 yearsthose younger than 45 years--oldold

Traumatic diaphragmatic rupture (TDR) injuries Traumatic diaphragmatic rupture (TDR) injuries occur in 0.8 to 8% of patients who sustain blunt occur in 0.8 to 8% of patients who sustain blunt (MVC and fall from height) and penetrating (MVC and fall from height) and penetrating traumatrauma

Mortality from TDR is 14Mortality from TDR is 14--50%. This increases to 50%. This increases to 77% when associated with shock and head injury77% when associated with shock and head injury

Sangster G, Ventura V, Carbo A, et. al

Background:Background: Complications and common associations of TDRComplications and common associations of TDR

Diagnosis of TDR missed in up to 48% of blunt trauma Diagnosis of TDR missed in up to 48% of blunt trauma patients on routine chest films and 30% of body CT scans. patients on routine chest films and 30% of body CT scans. Failure to identify the abnormality may cause acute or Failure to identify the abnormality may cause acute or delayed severe complicationsdelayed severe complications

CardiovascularCardiovascular--respiratory insufficiencyrespiratory insufficiency

Bowel strangulation and ischemiaBowel strangulation and ischemia

Left Left hemidiaphragmhemidiaphragm injured 4 times more commonly than injured 4 times more commonly than the right. Bilateral cases are rare (5the right. Bilateral cases are rare (5--8%)8%)

Most commonly herniated organs: Most commonly herniated organs: stomach > small and large bowel > spleen > liverstomach > small and large bowel > spleen > liver

Associated intraAssociated intra--abdominal injuries common abdominal injuries common (75% of TDR patients have associated intra(75% of TDR patients have associated intra--abdominal injury)abdominal injury)

Eren S, Kantarci M, Okur A.

Background:Background: Clinical symptoms as poor indicators of Clinical symptoms as poor indicators of

detecting TDRdetecting TDR

Most commonly experienced clinical symptoms Most commonly experienced clinical symptoms of TDR include of TDR include dyspneadyspnea, chest pain, abdominal , chest pain, abdominal pain, vomitingpain, vomiting

The clinical diagnosis of TDR is difficult and The clinical diagnosis of TDR is difficult and missed in up to 65% of patients missed in up to 65% of patients

Therefore, imaging is essential Therefore, imaging is essential

Sangster G, Ventura V, Carbo A, et. al

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

Menu of Tests:Menu of Tests: Plain Chest FilmPlain Chest Film

Plain film chest radiography 1Plain film chest radiography 1stst test of choice to test of choice to evaluate suspected TDRevaluate suspected TDR

Sensitivity of the chest plain film for the Sensitivity of the chest plain film for the detection of the DR range from 27 to 60% for detection of the DR range from 27 to 60% for leftleft--sided hernias and 17 to 33% for the rightsided hernias and 17 to 33% for the right

The most specific radiographic findings of DR The most specific radiographic findings of DR include include intrathoracicintrathoracic herniationherniation of hollow viscera of hollow viscera (small bowel, stomach, or colon) and (small bowel, stomach, or colon) and identification of the identification of the nasogastricnasogastric tube above the tube above the level of the left level of the left hemidiaphragmhemidiaphragm

Gelman R, Mirvis SE, Gens D.

http://radiologyinthai.blogspot.com/2008/09/blunt-diaphragmatic-rupture.html

Differential diagnosis for NG tube

tip overlying the

chest on plain film:

1) Tip is still inside the stomach – diaphragmatic rupture

2) Tip is outside of the GI tract – in a bronchus or the pleural space

3) Tube is outside the patient

Menu of Tests:Menu of Tests: Plain Chest Film, differential diagnosis for Plain Chest Film, differential diagnosis for

NG tube seen in left thoraxNG tube seen in left thorax

Supine AP Portable Plain Chest Film with NG tube tip in left thorax

Menu of Tests:Menu of Tests: Plain Chest Film, LimitationsPlain Chest Film, Limitations

Failure to diagnose TDR on plain films range from Failure to diagnose TDR on plain films range from 12 to 66%12 to 66%

Concurrent pulmonary abnormalities such as Concurrent pulmonary abnormalities such as pleural effusion, pulmonary contusion and pleural effusion, pulmonary contusion and atelectasisatelectasis can mimic or mask TDR on plain chest can mimic or mask TDR on plain chest filmsfilms

A A herniationherniation at the at the costocosto--phrenicphrenic angle may be angle may be misdiagnosed as a pleural effusion or misdiagnosed as a pleural effusion or hemothoraxhemothorax on the initial chest radiograph, and a thoracic on the initial chest radiograph, and a thoracic drainage tube could accidentally be placed into drainage tube could accidentally be placed into the herniated organsthe herniated organs

Shapiro MJ, Heidberg E, Durham RM, et. al.

Menu of Tests:Menu of Tests: CTCT

MultidetectorMultidetector CT (MDCT) has TDR CT (MDCT) has TDR detection rates of 73detection rates of 73––92% 92% = Gold standard for diagnosis= Gold standard for diagnosis

Because TDR is rarely isolated, CT is Because TDR is rarely isolated, CT is advantageous in the evaluation of advantageous in the evaluation of other associated injuries other associated injuries

Nchimi A, Szapiro D, Ghaye B, et. al.

Menu of Tests:Menu of Tests: CT Findings for TDRCT Findings for TDR

Diaphragm discontinuity and Diaphragm discontinuity and ““Dangling diaphragm signDangling diaphragm sign””73% sensitivity, 90% specificity73% sensitivity, 90% specificity

IntrathoracicIntrathoracic herniationherniation of abdominal contentsof abdominal contents55% sensitivity, 100% specificity 55% sensitivity, 100% specificity

““Collar sign:Collar sign:”” Constriction of the herniated abdominal Constriction of the herniated abdominal viscera viscera

67% sensitivity, 100% specificity67% sensitivity, 100% specificity

““Dependent viscera sign: Dependent viscera sign: ”” Visualization of the herniated Visualization of the herniated viscera against the posterior chest wallviscera against the posterior chest wall

100% sensitivity, 90% specificity100% sensitivity, 90% specificity

Desser TS. Edwards B, Hunt S, et. al.

Axial contrast CT through the abdomen.Arrowhead shows construction of the stomach as it passes through the diaphragmatic defect, this is the “Collar sign.” The relatively newly discovered “dangling diaphragm sign” is seen with the arrow, representing the torn free edge of the left hemidiaphragm

Desser TS. Edwards B, Hunt S, et. al.

Companion Patient 1:Companion Patient 1: The Collar and Dangling Diaphragm Signs on CTThe Collar and Dangling Diaphragm Signs on CT

Axial C+ CT through abdomen

Axial contrast CT through the thorax, showing the “Dependent viscera sign.” The stomach is lying adjacent to the posterior ribs instead of within the expected confines of the dome of the diaphragm

Desser TS. Edwards B, Hunt S, et. al; Bergin D, Ennis R, Keogh C, et. al.

Companion Patient 2:Companion Patient 2: The Dependent Viscera Sign on CTThe Dependent Viscera Sign on CT

Axial C+ CT through thorax

Menu of Tests:Menu of Tests: Lesser Used Studies to evaluate TDRLesser Used Studies to evaluate TDR

A barium study can be performed as a A barium study can be performed as a complement to diagnosis if the patient can complement to diagnosis if the patient can tolerate the study. If intestinal passage is tolerate the study. If intestinal passage is normal, barium filling intestinal loops are normal, barium filling intestinal loops are detected within the thoraxdetected within the thorax

MRI also used, but not a practical imaging MRI also used, but not a practical imaging technique in acute emergency setting for multitechnique in acute emergency setting for multi-- trauma patients, as it is a slower modality than trauma patients, as it is a slower modality than CTCT

Surgical Surgical laparotomylaparotomy may detect any unseen, may detect any unseen, subtle tears in the diaphragm. Preferred over subtle tears in the diaphragm. Preferred over thoracotomythoracotomy

Sangster G, Ventura V, Carbo A, et. al.

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

Our Patient J.C:Our Patient J.C: History of Present IllnessHistory of Present Illness

23 M helmeted, riding a scooter at 23 M helmeted, riding a scooter at 15 mph struck by a motor vehicle 15 mph struck by a motor vehicle and thrown from scooter 10 feetand thrown from scooter 10 feet

No LOC, with GCS of 14 at sceneNo LOC, with GCS of 14 at scene

Negative FAST ultrasoundNegative FAST ultrasound

Our Patient J.C:Our Patient J.C: Plain Chest FilmPlain Chest Film

PACS, BIDMCAP Supine Portable Chest Film

Patient J.C: Patient J.C: Plain Chest Film FindingsPlain Chest Film Findings

AP chest supine plain film

Lungs are clear with no pneumothorax

The right hemidiaphragm appears intact

Partial herniation of the stomach into the chest

Detailed evaluation limited by underlying trauma board

PACS, BIDMC

AP Supine Portable Chest Film

Our Patient J.C:Our Patient J.C: CT Scout ImageCT Scout Image

PACS, BIDMC CT C- Scout Image

Our Patient J.C: Our Patient J.C: CT Axial ImageCT Axial Image

CT C+ Axial Image through the thorax

PACS, BIDMC

Our Patient J.C: Our Patient J.C: CT Axial Image FindingsCT Axial Image Findings

Confirmation of Confirmation of herniationherniation of of stomachstomach partially partially into the thoraxinto the thorax

No comment No comment made about made about potential liver potential liver elevationelevation from from axial imagesaxial images

PACS, BIDMC

CT C+ Axial Image through the thorax

Our Patient J.C:Our Patient J.C: CT CT SagittalSagittal

ImageImage

PACS, BIDMCSagittal C+ CT image throughlevel of the stomach and left hemidiaphragm

DiscontinuityDiscontinuity of left of left hemidiaphgragmhemidiaphgragm with with herniationherniation of of stomachstomach into left into left chestchest

Sagittal C+ CT image throughlevel of the stomach and left hemidiaphragm

PACS, BIDMC

Our Patient J.C:Our Patient J.C: CT CT SagittalSagittal

Image FindingsImage Findings

Normal Patient vs. Our Patient J.C: Normal Patient vs. Our Patient J.C: CT CT SagittalSagittal

ImagesImages

PACS, BIDMC

NORMAL

Sagittal C+ CT images through level of the liverNormal patient on the left, Our Patient J.C on the right

OUR PATIENT J.C.

Normal Patient vs. Our Patient J.C: Normal Patient vs. Our Patient J.C: CT CT SagittalSagittal

Image FindingsImage Findings

Elevation of the dome Elevation of the dome of the liver into the of the liver into the chestchest in patient JC, in patient JC, compared to normal compared to normal smooth confines of smooth confines of upper dome of liver in upper dome of liver in normal patient on the normal patient on the leftleft

Confirmation of right Confirmation of right hemidiaphragmhemidiaphragm tear tear with with herniationherniation of dome of dome of liver not made on of liver not made on imaging, but later by imaging, but later by the surgeon during the surgeon during emergency emergency laparotomylaparotomy

PACS, BIDMC

NORMAL

Sagittal C+ CT images through level of the liverNormal patient on the left, Our Patient J.C on the right

OUR PATIENT J.C.

Our Patient J.C: Our Patient J.C: Post diaphragmatic repair CXR and CTPost diaphragmatic repair CXR and CT

PACS, BIDMC

Upright plain film of the chest Sagittal C+ CT Image through the liver

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

Companion Patient A.B.Companion Patient A.B.

22 M unrestrained rear seat 22 M unrestrained rear seat passenger in high speed MVC, with passenger in high speed MVC, with GCS of 5 at sceneGCS of 5 at scene

““RhonchiRhonchi”” appreciated in left lung on appreciated in left lung on auscultationauscultation

Companion Patient A.B: Companion Patient A.B: Plain Chest FilmPlain Chest Film

PACS, BIDMCAP Supine Portable Chest Film

Companion Patient A.B: Companion Patient A.B: Plain Chest Film FindingsPlain Chest Film Findings

AP chest supine plain filmAP chest supine plain film

Complete Complete opacificationopacification of of the left chest. the left chest. Multiple rib Multiple rib fracturesfractures including 2including 2ndnd, , 33rdrd, 4, 4thth left ribsleft ribs

The The mediastinummediastinum is is shifted to the rightshifted to the right

Impression: Impression: ““Given the trauma history Given the trauma history this could well represent this could well represent pulmonary contusion or pulmonary contusion or hemorrhagehemorrhage””

AP Supine Portable Chest Film

PACS, BIDMC

Companion Patient A.B: Companion Patient A.B: CT Scout ImageCT Scout Image

Left diaphragm Left diaphragm rupture with rupture with herniationherniation of the of the spleen, stomach, spleen, stomach, small bowel and a small bowel and a portion of the large portion of the large bowel into the left bowel into the left thoraxthorax

PACS, BIDMC

CT C- Scout Image

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

Embryology of the DiaphragmEmbryology of the Diaphragm

The diaphragm is created by the fusion of four discrete structures at the 7th week of development:

Septum transversum

Pleuroperitoneal membrane

Lateral body wall mesoderm

Dorsal mesentery

“Several Parts Make the Diaphragm”

Sugarbaker DJ: Adult Chest Surgery, www.accesssurgery.com

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

Diaphragmatic Trauma Diaphragmatic Trauma ““FakeFake--outout””

1: 1: Congenital HerniasCongenital Hernias

BBochdalekochdalek (90%) (90%) –– BBack of diaphragm, ack of diaphragm, left (5:1)left (5:1)

PosterolateralPosterolateral and result from failed fusion of and result from failed fusion of pleuroperitonealpleuroperitoneal folds at the eighth week of folds at the eighth week of gestationgestation

MMorgagniorgagni –– MMiddle of diaphragmiddle of diaphragm

Foramen of Foramen of MorgagniMorgagni hernias are located hernias are located posterior to the posterior to the xiphoidxiphoid process and are process and are caused by failed migration of the cervical caused by failed migration of the cervical somitessomites

Hanna W, Ferri L, Fata P, et. Al.

In newborns, if In newborns, if massive defect, massive defect, apparent on plain apparent on plain film; morbidity film; morbidity related to degree of related to degree of pulmonary pulmonary hypoplasiahypoplasia

Differentiate from Differentiate from TDR by absence of TDR by absence of traumatrauma

Diaphragmatic Trauma Diaphragmatic Trauma ““FakeFake--outout””

1: 1: Congenital Hernias on CXRCongenital Hernias on CXR

Images courtesy of Dr. Julia Rissmiller, BIDMC

Supine plain film of the chest; Bochdalek hernia

Supine plain film of the chest; Morgagni hernia

Diaphragmatic Diaphragmatic ““FakeFake--outout””

2: 2: Diaphragmatic Diaphragmatic EventrationEventration

Congenital absence of functional Congenital absence of functional diaphragmatic musculature with diaphragmatic musculature with incomplete incomplete muscularizationmuscularization of of the diaphragm and a thin the diaphragm and a thin membranous sheet replacing a membranous sheet replacing a portion of the diaphragmatic portion of the diaphragmatic musclemuscle

Frequently involves the Frequently involves the anteromedialanteromedial portion of the portion of the rightright hemidiaphragmhemidiaphragm

Diaphragm retains its continuity Diaphragm retains its continuity and attachments to the costal and attachments to the costal marginmargin

Weakened Weakened hemidiaphragmhemidiaphragm is is displaced into the thorax, which displaced into the thorax, which can compromise breathing can compromise breathing

http://www.radswiki.net/main/index.php?title=File:Diaphragmatic_eventration_001.jpgSangster G, Ventura V, Carbo A, et. al.

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

AgendaAgenda

Background

Menu of Tests

Patient J.C.

Companion Patient A.B.

Embryology of the Diaphragm

Diaphragmatic Trauma “Fake-outs”

Conclusions

ConclusionsConclusions

TDR is an uncommon injury (0.8 TDR is an uncommon injury (0.8 –– 8% of traumas), but 8% of traumas), but with a high mortality (14 with a high mortality (14 -- 50%)50%)

TDR is difficult to diagnose clinically, and frequently missed TDR is difficult to diagnose clinically, and frequently missed on supine plain filmson supine plain films

CT is the gold standard noninvasive diagnostic modality and CT is the gold standard noninvasive diagnostic modality and allows visualization of other associated intraallows visualization of other associated intra--abdominal abdominal injuriesinjuries

Beware TDR Beware TDR ““fakefake--outsouts”” in the absence of trauma: in the absence of trauma: congenital hernias and diaphragmatic congenital hernias and diaphragmatic eventrationeventration

Always wear a seatbelt Always wear a seatbelt

AcknowledgementsAcknowledgements

Gillian Lieberman, MDGillian Lieberman, MD

Diana Ferris, MDDiana Ferris, MD

Julia Julia RissmillerRissmiller, MD, MD

James Kang, MDJames Kang, MD

Maria Maria LevantakisLevantakis

ReferencesReferences1. Sangster G, Ventura V, Carbo A, et. al. Diaphgragmatic rupture: a frequently missed

injury in blunt thoracoabdominal trauma patients. Am Soc Emergency Radiol 2007; 13(5):225-30.

2. Eren S, Kantarci M, Okur A. Imaging of diaphragmatic rupture after trauma. Clin Radiol 2006; 61(6): 467-77.

3. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991; 156: 51-57.

4. Nchimi A, Szapiro D, Ghaye B, et. al. Helical CT of blunt diaphragmatic rupture. AJR 2005; 184: 24-30.

5. Shapiro MJ, Heidberg E, Durham RM, et. al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996; 51: 27-30.

6. Larici AR, Gotway MB, Litt HI, et. al. Helical CT with sagittal and coronal reconsutructions: accuracy for detection of diaphragmatic injury. AJR 2002; 179: 451-457.

7. Bergin D, Ennis R, Keogh C, et. al. The dependent viscera sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR 2001; 177: 1137-1140.

8. Desser TS. Edwards B, Hunt S, et. al. The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture. Emerg Radiol 2010; 17(1): 37-44.

9. Hanna W, Ferri L, Fata P, et. al. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008; 85: 1044-1048.

10. Reda E. Al-Refaie, Ebrahim Awad, Ehab M. Mokbel. Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients. Interact CardioVasc Thorac Surg 2009; 9:45-49.