Traumatic Diaphragm Injury (Diaphragmatic Rupture)

What to do right away

After a major crash, fall or wound to the torso:

• call 911 or your local emergency number
• do not remove impaled objects
• keep the person still and warm; sit them up if breathing is easier and no spine injury is suspected
• any penetrating wound between the nipples and the lower ribs (or the tips of the shoulder blades at the back) can injure the diaphragm, even if it looks small

How the diaphragm tears

Blunt trauma

A sudden rise in abdominal pressure, for example from a side-impact car crash or a fall onto the abdomen, can burst the diaphragm. Blunt tears tend to be large, often 5 to 10 cm or more, usually on the left side.

Penetrating trauma

Stab and gunshot wounds create smaller holes, often 1 to 2 cm. These are easy to miss on imaging but can enlarge over time as abdominal organs gradually push through.

Associated injuries

Diaphragm tears rarely occur alone. People often also have rib fractures, lung injuries, liver or spleen tears, pelvic fractures or head injuries. See chest trauma and abdominal trauma.

Why diaphragm injuries are missed

• symptoms overlap with other injuries
• small tears may not show on initial x-rays or CT
• patients on a ventilator have positive pressure in the chest, which can keep organs from herniating until the breathing tube is removed
• herniation can develop slowly over months or years

Phases of traumatic diaphragmatic hernia

Symptoms

• shortness of breath
• chest pain or upper abdominal pain
• shoulder-tip pain (referred through the phrenic nerve)
• reduced breath sounds on one side, with bowel sounds heard in the chest
• nausea, vomiting, pain after eating (later)
• signs of bowel obstruction if organs are trapped

Diagnosis

• Chest x-ray: may show stomach or bowel in the chest, a raised or irregular diaphragm, or a nasogastric tube curling into the chest; often normal with small tears.
• CT scan: the main test; signs include a discontinuous diaphragm, organs in the chest, and the "collar sign" where organs are pinched at the tear.
• MRI: sometimes used for stable patients with uncertain findings.
• Diagnostic laparoscopy or thoracoscopy: recommended for many penetrating wounds to the lower left chest, because small tears can be invisible on scans.

Treatment

All traumatic diaphragm tears should be repaired, because they do not heal and risk later herniation and strangulation.

• Acute injuries: usually repaired through the abdomen (laparotomy or laparoscopy), which allows the surgeon to treat associated abdominal injuries. Herniated organs are returned to the abdomen and the tear is stitched closed.
• Delayed (chronic) hernias: often repaired through the chest (thoracotomy or thoracoscopy) because adhesions form between organs and lung; large defects may need a mesh patch.
• Supportive care: breathing support, chest drains for associated lung injuries, nutrition and pain control.

Recovery and outlook

Recovery depends largely on the other injuries. After an isolated repair, hospital stay is often 5 to 10 days, and heavy lifting is avoided for about 6 weeks. Mortality is mainly driven by associated injuries and by delayed diagnosis with strangulated bowel, which carries a high risk.

For non-traumatic causes of diaphragm problems, such as strain or nerve paralysis, see diaphragm injury.

Frequently asked questions

What is a traumatic diaphragm injury?

It is a tear in the diaphragm caused by a blunt impact, such as a car crash or fall, or by a penetrating wound such as a stabbing. The tear can allow abdominal organs to move into the chest, affecting breathing and risking trapped bowel.

Why are diaphragm ruptures often missed?

They usually occur alongside other serious injuries, early scans can look normal, especially with small tears, and organs may not herniate until later. Some are found months or years afterward when symptoms of a hernia develop.

What are the symptoms of a ruptured diaphragm?

Symptoms include breathlessness, chest or upper belly pain, pain in the shoulder tip, and later indigestion, fullness after meals, nausea or vomiting. Severe pain with vomiting and no passing of gas can mean trapped bowel, an emergency.

Does a torn diaphragm heal on its own?

No. The constant movement of breathing and pressure differences between the chest and abdomen prevent healing. All traumatic diaphragm tears need surgical repair to prevent herniation and strangulation of abdominal organs.

How long is recovery after diaphragm repair surgery?

After an uncomplicated repair, many people go home within 1 to 2 weeks and return to normal activities over 6 to 12 weeks, avoiding heavy lifting for about 6 weeks. Recovery can take much longer when there are other major injuries.