What is Diaphragm Injury?
The diaphragm is a muscle in your body composed of several parts, including a central tendon and sections that stretch to the ribs, sternum, and lower back. These side sections are an extension of the slanted muscles in your body. At rest, the diaphragm is located near the area between the fifth and sixth ribs. It doesn’t fully separate the chest and the stomach areas. Its location in the middle of the body, and the fact that it moves when we breathe, makes it a possible site for injury in both chest and stomach trauma.
What Causes Diaphragm Injury?
Diaphragmatic rupture, or a tear in the diaphragm, often happens in blunt traumas due to a sudden increase in pressure within the abdomen. In cases of stabbing or gunshot wounds, these injuries to the diaphragm may go unnoticed and not initially diagnosed.
Risk Factors and Frequency for Diaphragm Injury
Diaphragmatic injuries, while uncommon, can be a serious outcome of trauma. They can occur in anywhere from 0.8% to 15% of all traumas that impact both the chest and the abdomen. Penetrating trauma, like gunshot or knife wounds, can harm the diaphragm in 10% to 15% of cases, while blunt force trauma only results in diaphragmatic injuries about 1.6% of the time. Gunshot wounds, in particular, have a higher chance of resulting in an injury to the diaphragm and even herniation.
Although these injuries are not common, trauma with enough force to damage or tear the diaphragm often also causes injury to nearby organs. This can lead to an increased death rate, up to 20%, unrelated to the original injury to the diaphragm. Consequently, death rates are usually higher for blunt force injuries to the diaphragm than for penetrating ones. Sometimes, injuries to the diaphragm aren’t noticed right away, and this can lead to serious health problems years after the original trauma.
Signs and Symptoms of Diaphragm Injury
Patients with penetrating injuries in the thoracoabdominal region, which is the area around the chest and abdomen, may show up soon after getting hurt. It is not easy to detect diaphragm injuries early on, especially from penetrating traumas, as there are often no immediate symptoms and other injuries might mask it. Therefore, medical professionals need to be highly alert to such possibilities. The position of the diaphragm can go up and down with each breath, so doctors need to be aware of potential diaphragm injuries even if a wound is as high as the fourth rib space or as low as right under the ribcage.
Diaphragm ruptures often happen due to blunt traumas, like car accidents or falling from great heights. Any force that is strong enough to tear the diaphragm can also cause noticeable injuries like broken ribs, bruised lungs, damage to solid organs and cuts, or harm to hollow organs. During car accidents, the pressure from an airbag or handlebar can be enough to rupture the diaphragm.
If patients show up after a while, they may have symptoms such as difficulty breathing, nausea, and vomiting, which may be related to a past car accident or another blunt trauma. If internal organs have slipped through a diaphragm tear into the chest, things like gut movements might be heard in the chest upon examination. In some cases, if the bowel gets trapped and cut off from blood supply, it can lead to severe symptoms like unproductive retching, inability to pass gas or stool, and if untreated, severe infection and rupture.
Testing for Diaphragm Injury
Injuries to the diaphragm, a muscle that helps us breathe, can often be missed in the early stages after a blunt or incisive injury. In such cases, using an ultrasound technique called FAST (Focal Assessment with Sonography for Trauma) can be helpful. If this test doesn’t show a bright, curved line above the liver or spleen, it could mean there’s a large injury to the diaphragm.
A chest x-ray is another common initial test, but it could miss as many as half of all diaphragm injuries. The x-ray might show one half of the diaphragm unusually high on the side of the injury, or see signs of organ displacement that can look like gas bubbles. However, these features can be mistaken for a buildup of fluid in the lungs or an infection that produces gas, leading to an improper decision to insert a chest tube on the affected side.
In more severe cases, other organs from the abdomen might move through the injured diaphragm. Inserting a tube through the nose into the stomach can aid in detecting diaphragmatic rupture. If an x-ray shows the tube coiled up in the chest, it’s highly suggestive of a broken diaphragm.
If the x-ray doesn’t show clear results, a more detailed scan, known as computed tomography (CT) scan of the chest and abdomen, is more precise in diagnosing a ripped diaphragm. Signs to look for on a CT scan might include a break in the diaphragm, abdominal organs moving out of place, abdominal organs squeezing through the diaphragm defect, or parts of the diaphragm floating freely – all these are worrying signs of a diaphragm injury.
When the results of these imaging procedures still leave room for doubt, a procedure called diagnostic laparoscopy can be performed under general anesthesia. This involves inserting a camera into the body to visualize the diaphragm directly. However, due caution must be exercised as this procedure can induce a lung collapse in patients with diaphragm injury, so monitoring the patient’s vital signs throughout the procedure is critical.
Once detected, diaphragm injuries are then ranked from I to V according to a scale devised by the American Association for the Surgery of Trauma in 1994. Injuries from penetrative forces usually lead to minor tissue bruising or cuts less than 2 cm long, while injuries from more direct impact can result in more extensive tissue loss.
Treatment Options for Diaphragm Injury
In cases where injuries to the diaphragm are identified quickly, a doctor can perform open surgery to correct any internal organ shifts and repair the injury. If the patient is stable and there are no other pressing issues, a less invasive form of surgery called laparoscopy can be performed instead.
To prepare for surgery, the patient is laid on their back and their chest is prepped and covered in case a bigger incision is needed. A tube is inserted into the patient’s nose or mouth to relieve pressure in the stomach. The surgeon then moves several internal organs, like the spleen, stomach, colon, and liver, to get a better view of the diaphragm.
The surgeon checks the whole abdomen and moves any shifted organs back to their correct locations. If there is any substance spillage, the chest cavity is thoroughly cleaned with an antibiotic solution. If the injury to the diaphragm is large, it may need to be made bigger to treat the problem properly. A chest tube may be inserted if there are concerns about leftover contamination or blood accumulation. In emergency situations, the injury might be temporarily covered and left for a more thorough repair later.
If a diaphragm tear is not diagnosed immediately and organs move through it, surgery might be delayed. In these cases, other surgeries, like video-assisted thoracic surgery or thoracotomy, can be used to treat the problem. The doctor can examine and fix any moved organs, get rid of any abnormal connections, and move organs back to their right places. Before surgery, patients may need to clean their bowel to reduce the risk of bowel injury during the surgical procedure.
After identifying the injury, the surgeon gets rid of any dead tissue. Then, they repair the tear using strong, non-absorbable sutures, or stitches. If the tear is too large to be sewn up directly, the doctor uses a synthetic mesh to bridge the gap and holds it in place with suture. If the injury is significantly contaminated, a temporary biological mesh can be used until it can be definitively repaired with a synthetic mesh at a later date. In certain cases, a combined surgery involving both the chest and abdomen may be required.
After surgery, there may be complications like breakage of the repair, diaphragm paralysis due to nerve injury, and difficulty in breathing. To prevent the lung from collapsing, patients are encouraged to do breathing exercises and are given adequate pain relief. The surgeon should closely monitor the patient to detect and manage any potential complications, as a delayed diagnosis could lead to secondary problems like chest cavity infection, abscesses in the diaphragm, and even the spread of the infection that might cause multiple organ failure.
What else can Diaphragm Injury be?
On an upright chest x-ray, doctors may sometimes misinterpret organs that have shifted out of place as a fluid build-up in the chest (pleural effusion) or a pocket of pus (loculated empyema). Performing a procedure to drain the chest at this stage can often lead to damage to the bowels and contamination within the chest cavity.
More often though, damage to the diaphragm, a muscle that assists in breathing and separates the chest from the abdomen, is simply not seen. Especially in cases where there’s no strong reason to perform exploratory surgery, such an injury could easily go unseen. The way the injury happened, how severe it is, and where it is located should all increase the doctor’s suspicion of diaphragm involvement. This is especially important because overlooking such an injury can lead to serious health problems later on.
What to expect with Diaphragm Injury
If diaphragm injuries are identified and repaired promptly, they usually heal well due to a strong blood supply. The most serious complications from a faulty diaphragm include hernias and subsequent abdominal damage. If a diaphragmatic hernia is not diagnosed until years after an injury, it can be difficult to fix and may result in permanent damage.
