Diaphragmatic Rupture (Traumatic Diaphragm Injury)

First aid after major trauma

1. Call 911 or your local emergency number.
2. Keep the person still, especially if a neck or back injury is possible.
3. If they are struggling to breathe and conscious, let them sit in the position they find most comfortable unless spinal injury is suspected.
4. For a penetrating wound, apply firm pressure around (not on) any embedded object and do not remove it.
5. Do not give food or drink.

How the diaphragm is injured

The diaphragm contracts with every breath, pulling air into the lungs. It is a thin muscular sheet with openings for the esophagus, aorta and main vein.

• Blunt trauma: a sudden rise in abdominal pressure, as in a side-impact car crash, bursts the diaphragm, usually causing a large tear of several centimeters. Most blunt ruptures are on the left side.
• Penetrating trauma: stab and gunshot wounds create smaller holes, which are easily missed but can enlarge over time.

Diaphragmatic injury occurs in a small percentage of major trauma patients and almost always comes with other injuries, such as rib fractures, pneumothorax, hemothorax, and injuries to the spleen, liver, pelvis or head.

Symptoms

Early symptoms are often masked by other injuries:

• shortness of breath and fast breathing
• chest or upper belly pain
• pain referred to the shoulder tip, because the diaphragm shares nerve supply with the shoulder
• reduced breath sounds or bowel sounds heard in the chest
• low oxygen levels and low blood pressure

Delayed presentation

Small tears may cause no symptoms at first. Over months or years, the negative pressure in the chest gradually pulls abdominal organs through the defect. People may develop:

• breathlessness and chest discomfort
• pain or fullness after eating, nausea and vomiting
• symptoms of bowel obstruction
• strangulation of herniated bowel or stomach, which is a surgical emergency

Diagnosis

Diagnosis is challenging, and a high level of suspicion is needed after trauma to the lower chest or upper belly.

• Chest X-ray: may show a raised or irregular diaphragm, bowel gas or a nasogastric tube coiled in the chest. It is normal in many cases.
• CT scan: the main imaging test in stable patients; shows discontinuity of the diaphragm or organs in the chest.
• Ultrasound in the trauma bay can raise suspicion.
• Laparoscopy or thoracoscopy: the most accurate way to find small tears, especially after penetrating wounds to the left lower chest.
• MRI: sometimes used in stable patients with delayed presentations.

Treatment

All diaphragmatic ruptures need surgical repair, because the tear does not heal on its own and organs can herniate and strangle.

• Acute injuries: usually repaired through the abdomen (laparotomy or laparoscopy), which also allows treatment of other abdominal injuries.
• Delayed (chronic) hernias: often repaired through the chest (thoracoscopy or thoracotomy) because organs may be stuck to the lung.
• Repair: the edges are stitched together, and large defects may need a mesh patch.

Supportive care includes oxygen or ventilation, a chest drain for associated pneumothorax or hemothorax, and a nasogastric tube to decompress the stomach.

Complications

• lung compression and respiratory failure
• strangulation and death of herniated bowel or stomach
• infection, including empyema
• recurrence of the hernia after repair
• complications from associated injuries

Outlook

The outcome depends mainly on the severity of other injuries. The diaphragm repair itself usually has good results. Delayed diagnosis with strangulated bowel carries a much higher risk.

Frequently asked questions

What causes a ruptured diaphragm?

Most ruptured diaphragms are caused by high-energy blunt trauma, especially car crashes, which suddenly increase pressure in the abdomen. Stab and gunshot wounds to the lower chest or upper belly are the other main cause. Spontaneous rupture is very rare.

What are the symptoms of a ruptured diaphragm?

Symptoms include shortness of breath, chest or upper belly pain, shoulder-tip pain and low oxygen levels. They are often hidden by other injuries. Delayed cases can cause breathlessness, pain after eating, vomiting or signs of bowel obstruction.

Can a diaphragm tear heal on its own?

No. The constant movement of the diaphragm and the pressure difference between chest and belly prevent healing, and the tear tends to enlarge. Surgical repair is needed to prevent organs from herniating into the chest.

Can you live with a torn diaphragm?

Some people live for months or years with an undetected tear, but there is an ongoing risk that the stomach or bowel will herniate and become trapped. Once discovered, repair is recommended.

How long does it take to recover from diaphragm repair surgery?

Recovery depends on other injuries. After laparoscopic repair of an isolated tear, many people leave the hospital within a few days and recover over several weeks. Open surgery and associated injuries lengthen recovery.