Elsevier

Annals of Emergency Medicine

Volume 18, Issue 12, December 1989, Pages 1326-1330
Annals of Emergency Medicine

Special contribution
Blunt rupture of the diaphragm: Mechanism, diagnosis, and treatment

https://doi.org/10.1016/S0196-0644(89)80270-7Get rights and content

Summary

In the absence of respiratory distress and massive visceral herniation, the diagnosis of blunt diaphragmatic disruption can be difficult. 5,8,10,12., 13., 14., 15. This is particularly true for diaphragmatic injuries confined to the right hemidiaphragm.1,4,13,24., 25., 26. Because diagnostic delay and strangulation are associated with notable increases in mortality and morbidity, it is important to identify the injury as early as possible.21

Victims of lateral impact motor vehicle collisions are more likely to experience rupture of the diaphragm than victims of frontal collisions. Occupants exposed to left lateral impacts are at greatest risk. The side of diaphragmatic rupture correlates with the direction of impact. The right hemidiaphragm is more resistant to rupture. Deformation shear is a more plausible mechanism for diaphragmatic rupture after lateral impacts.

Knowledge of the mechanisms that produce this injury combined with information regarding the victim's seat position and direction of the impacting force should lead to a high index of clinical suspicion for diaphragmatic rupture. Chest radiography and diagnostic peritoneal lavage will establish the correct diagnosis in almost 90% of the patients with acute diaphragmatic disruption. 7., 8., 9.,15 Additional diagnostic studies are reserved for the remaining 10% of patients.

Due to the pressure differential between abdomen and thorax, the natural history of these injuries is one of enlargement, and none can be expected to heal spontaneously. Once the diagnosis has been established, the treatment of every diaphragmatic disruption is surgical repair.

References (34)

  • LucidoJL et al.

    Rupture of the diaphragm due to blunt trauma

    Arch Surg

    (1963)
  • McCuneRP et al.

    Rupture of the diaphragm caused by blunt trauma

    J Trauma

    (1976)
  • MorganAS et al.

    Blunt injury to the diaphragm: An analysis of 44 patients

    J Trauma

    (1986)
  • Rodriguez-MoralesG et al.

    Acute rupture of the diaphragm in blunt trauma: Analysis of 60 patients

    J Trauma

    (1986)
  • WaldschmidtML et al.

    Injuries of the diaphragm

    J Trauma

    (1980)
  • WardRE et al.

    Diaphragmatic disruption secondary to blunt abdominal trauma

    J Trauma

    (1981)
  • EbertPA et al.

    Traumatic diaphragmatic hernia

    Surg Gynecol Obstet

    (1967)
  • Cited by (133)

    • Relevance of early CT scan diagnosis of blunt diaphragmatic injury: A retrospective analysis from the Northern French Alps Emergency Network

      2019, Journal of Visceral Surgery
      Citation Excerpt :

      Sudden elevation of intra-abdominal pressure secondary to blunt abdominal trauma can lead to localized rupture of the posterior part of the diaphragm, the embryonic weak spot. Another mechanism can be responsible when the trauma impact is lateral or when there are associated rib fractures, in which the peripheral attachments of the diaphragm are torn [7,10,15] (Fig. 3). Diaphragmatic ruptures occur more frequently on the left (65% of cases); bilateral rupture is exceptional [1,6].

    View all citing articles on Scopus

    Presented at the American College of Emergency Physicians Winter Symposium in Tampa, Florida, March 1989.

    View full text