Trauma: Diaphragm Trauma

Diaphragm Injury

General

  • Most Common on Left
  • Most Common After Blunt Trauma
  • Typical Severity by Mechanism:
    • Stabs & Low-Velocity GSW: Grade I-II
    • Blunt: Grade III-IV
    • High-Velocity GSW, Shotgun or Explosion: Grade V

AAST Diaphragm Injury Scale

Diagnosis

  • Dx: CXR (Gastric Bubble in Chest)
    • If Not Obvious: CT or Laparoscopy

Treatment

  • Grade I: Conservative
  • Grade II-V: Primary Repair

Surgical Repair

  • Use Permanent Sutures (Horizontal Mattress)
  • If Large or Under Tension: Use Mesh
    • Consider Incision of Peripheral Attachments and Reattachment 2-3 Interspaces More Cephalad
  • For Complete Avulsion: Reattach to Ribs
    • Place Sutures Circumferentially Around the Ribs
    • May Also Consider Using Rib Suture Anchors
  • Timing/Approach:
    • Immediate Dx (< 1 Week): Transabdominal Approach
    • Delayed Dx (> 1 Week): Transthoracic Approach
      • To Evaluate Viscera & Adhesions

Diaphragm Laceration & Repair 1

Traumatic Diaphragmatic Hernia on CXR 2

References

  1. Pakula A, Jones A, Syed J, Skinner R. A rare case of chronic traumatic diaphragmatic hernia requiring complex abdominal wall reconstruction. Int J Surg Case Rep. 2015;7C:157-60.(License: CC BY-NC-ND-3.0)
  2. Vyas PK, Godbole C, Bindroo SK, Mathur RS, Akula B, Doctor N. Case-based discussion: an unusual manifestation of diaphragmatic hernia mimicking pneumothorax in an adult male. Int J Emerg Med. 2016 Dec;9(1):11. (License: CC BY-4.0)