Diaphragm Injury

DEFINITION
Disruption to the major muscle of breathing as a result of thoracic trauma, possibly allowing entry of abdominal contents into the chest and compromising ventilation.
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EPIDEMIOLOGY
Chest trauma
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AETIOLOGY
Trauma.


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BIOLOGICAL BEHAVIOUR

Pathophysiology
More common on the left (?liver protection / hiding of defects).
Blunt trauma leads to large radial tears
--> lead to herniation
Penetrating trauma can lead to smaller perforations
--> may take years before herniation occurs.

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MANIFESTATIONS

Breathing impairment
The appearance of peritoneal lavage fluid in the chest drain also confirms the diagnosis.
Features of abdo visceral herniation (left sided almost always).
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INVESTIGATIONS

CXR

Rupture requires a high index of suspicion - initial XR is not sensitive.
Signs:
a) elevation (can go to 4th ICS with expiration)
b) disruption (stomach, bowel cas, NG tube above)
- if an injury to the left side is suspected, insert an NG tube
- this eliminates need for special contrast studies
c) irregular or obscured (overlying fluid).
d) contralateral medistinal shift
e) widening of cardiac silouette (if abdo contents herniate into it)
f) pleural effusion

Contrast study
If the diagnosis is not clear, an upper GI contrast study should be performed.


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MANAGEMENT

Direct repair
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REFERENCES
ATLS