Traumatized Diaphragm

1. PHYSIOTHERAPY MANAGEMENT
OF TRAUMATIZED DIAPHRAGM
AGORO, B. ZAINAB
FEBRUARY 2019.

2. Introduction
• The diaphragm is a double-domed musculoskeletal
partition, -crucial for respiration and maintenance if
intra-abdominal pressure, -injuries result in
significant ventilatory compromise.
• Traumatic diaphragmatic injuries (TDI) include
wounds and diaphragm ruptures due to
thoracoabdominal blunt or penetrating trauma
2

3. Introduction
• TDI are usually occult and can easily be missed
• An accurate diagnosis requires a high index of
suspicion as missed TDI may result in herniation and
strangulation of inta-abdominal viscera into the
thoracic cavity.
• Herniation can interfere with breathing, and blood supply
cut off to organs that herniated through the diaphragm
3

4. Etiology
• Causes:
Blunt trauma: RTA’s , falls from height
Penetrating trauma: gunshot injuries, stab wounds, lesions
Iatrogenic causes
• With penetrating trauma, the contents of the abdomen
may not herniate into the chest cavity right away
• Rare case, phrenic nerve injury diaphragm paralysis
4

5. Incidence and Epidemiology
• The Incidence of TDI ranges from 0.8 to 8%, but the true
incidence is likely to be higher due to missed or delayed
diagnosis
• Left-sided TDI is more common, representing 75% of
cases
• Right sided TDI (35-49%) of cases, harder to diagnose
• Bilateral TDI is an extremely rare occurrence, comes
with blunt mechanism 5

6. Relevant Anatomy
• is divided into two parts:
the lumbar diaphragm
and costal diaphragm
• It originates anteriorly
from the xiphoid,
sternum, and the ribs and
costal cartilaeges 7-12, as
well as posteriorly from
the lumbar vertebrae by
means of the left and
right crura
6

7. Relevant Anatomy cont’d
• The diaphragm inserts
into the central tendon
which is fused with the
pericardium.
• It allows the passage of 3
large structures: The
inferior vena cava and
the right phrenic nerves,
the oesophagus and the
abdominal aorta
7

8. Relevant Anatomy cont’d
• The lumbocostal trigone, a thin area of degenerative
muscle on the left diaphragm above the lateral
arcuate ligament, represents an embryological
transitional region between the costal and lumbar
diaphragm.
• Nerve supply is via the phrenic nerves (C3, C4 and
C5)
8

9. Pathophysiology
• In blunt trauma, abrupt change in IAP cause majority
of injuries
• From normal pressure varies from +2  +10cmH20
to pressure about 100cmH20
• This pressure gradient contributes to the initial injury
• There are also radial forces that pull the defect edges
apart.
9

10. Pathophysiology Cont’d
• Overtime, this can lead to pulmonary dysfunction
• Studies have shown consistent weakness on left side
of diaphragm  location of lumbocostal trigone,
esophageal hiatus
• Penetrating mechanism of TDI produce smaller
injuries, typically less than 1cm in diameter
10

11. Clinical Presentation
• Clinical presentation varies depending on the
mechanism of injury.
• Blunt TDI commonly occur in poly-traumatized
patient and in poly-traumatized patient, with early
sypmtoms being missed most of the time.
• Presenting symptoms usually due to herniation of
intra-abdominal organs
11

12. Clinical Presentation Cont’d
• -chest pain, recurrent shortness of breath, nausea and
vomitting, epigastric discomfort, abdominal pain.
• Bowel sounds may also be heard in left-sided hernia
associated with bowel loops in the chest.
• Grimes divided the clinical presentations of TDI into
3 phases. -the acute phase -the latent phase -
obstructive phase
12

13. Acute Phase
 Abdominal pain
 Concurrent Injuries
• Chest/abdominal wall
• Hemopneumothorax
• Intraabdominal organs
• Pelvis
• Head
• Extremities
 Respiratory distress
 Cardiac dysfunction
 Chest x-ray film
abnormality
 Defect detected at
laparatomy
Latent Phase
 Upper gastrointestinal
complaints
 Pain, left upper quadrant
or chest
 Pain, left shoulder
 Dyspnea
 Orthopnea
 Decreased breath sounds
 Abnormal chest x-ray film
findings
Obstructive Phase
 Nausea and vomiting
• Unrelenting abdominal
pain
• Prostration
 Respiratory distress
 Strikingly abnormal chest
x-ray film findings.
13

14. Diagnosis
• Although delayed diagnosis is common, classical signs and
symptoms coupled with chest radiograph can lead to a speedy
diagnosis.
• Diagnosis requires a high index of suspicion.
• Physical findings include decreased chest expansion,
impairment of resonance, adventitious breath sounds,
cyanosis, dyspnoea, abdominal pain and guarding
14

15. Diagnosis
• Plain chest x-ray not 100% accurate in detecting TDI
but the following signs could be helpful in making
the diagnosis:
• Inability to trace the normal hemi diaphragm contour
• Intrathoracic herniation of a hollow viscus (stomach, colon,
small bowel) with or without focal constriction of the
viscus at the side of the tear (collar sign)
15

16. • If large, the positive mass
effect may cause a
contralateral mediastinal
shift
• Visualization of a
nasogastric tube above the
hemidiaphragm on the left
side (fig. 2)
• Left hemidiaphragm
higher than the right
16

17. Diagnosis
• Multidetector CT best imaging modality for
diagnosing TDI in trauma patients. Allows for thinner
slicing and more detailed imaging in a shorter time.
• In other cases, the lesion is only deteced during
laparatomy for other injuries
17

18. Complications
• Pneumonia
• Empyema
• Subphrenic/intra-abdominal abcess
• Hemi diaphragmatic paralysis secondary to iatrogenic
phrenic nerve injuries.
18

19. Management
• Medical
• First line of management would focus on
resuscitation (ABC).
• Ensure a patent airway
• Assist ventilation if required
• Restore circulation by stopping external haemorrhage and
effective volume restoration
19

20. Management
• Surgical
• Acute cases of TDI are better managed via a
laparatomy as this also rules out and treat associated
intra-abdominal organ injuries.
• Delayed cases are better managed via a thoracotomy
because of intra-thoracic adhesions
20

21. Physiotherapy Management
• Assessment
• Following Laparatomy and thoracotomy, there is
overwhelming evidence of changes in lung function and
associated clinical manifestation.
• Changes include reduction in lung volume, reduction in
functional residual capacity, slowing of mucociliary
clearance, and abnormalities in gaseous exchange.
21

22. Physiotherapy Management cont’d
• Other clinical manifestation include post-thoracotomy pain
syndrome and ipsilateral reduction in upper extremity range of
motion and strength
• Assessment is primraily focused on physical examination,
chest expansion, Arterial blood gases (ABG) analysis,
pulmonary function test, chest x-ray, oxygen saturation,
peripheral muscle strength and cardiopumunary exercise
testing
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23. Physiotherapy Management cont’d
• Others are respiratory rate and pattern of breathing
• Patients usually present with monotonous shallow
breathing without spontaneous deep breath, increase
in respiratory rate, decreased tidal column and
significant change in minute ventilation
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24. Physiotherapy Management
• Aims of intervention
• Generally the main aims in the postoperative phase
are to maintain adequate ventilation, to assist in the
removal of any excess lung secretions and to aid in
the general positioning, bed mobility and early
ambulation of the patient.
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25. Physiotherapy Management
• Prevention of reduced joint movements or poor posture
secondary to incisions or tubes, monitoring of adequate
pain relief .
• Physiotherapy techniques
• Early mobilization: A graduated walking programme
adapted to suit each patient should be encouraged with
the introduction of stair climbing at an appropriate stage.
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26. Physiotherapy Management
• Breathing exercises: DBExs are taught, the patient is
instructed to relax the shoulder and upper chest, take a
slow deep breath in to fill up the lungs as fully as they
can, hold breath for 3 ses, and breathe out slowly through
the mouth.
• Incentive spirometry: The purpose of IS is to increase the
volume of air inspired.
26

27. Physiotherapy Management
• Active cycle of breathing : combination of breathing
control, thoracic expansion exercise and forced
expiratory technique. Used in airway clearance and
improving pulmonary function
• Thoracic expansion exercise: involve a combination of
DBExs and upper limbs movement to enhance the ribcage
expansion.
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28. Physiotherapy Management
• These exercises could be further advanced by the usage
of therabands or weights to start with resistance training
for the upper body.
• Huffing and coughing: used in clearing secretions from
large airways
• TENS: The use of TENS has been shown to decrease pain
from shoulder flexion in patients undergoing axillary
thoracotomy
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29. Conclusion and Recommendation
• Traumatic injuries of the diaphragm are often hidden
and can be masked by other violent injuries
associated with polytrauma. A high index suspicion
and the use of relevant radiological investigation
should help in early diagnosis. Mobilization, deep
breathing exercise, thoracic expansion exercise
should also be integrated early into patients care.
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30. Conclusion and Recommendation
• Trauma registries should be created in hospitals for
easier access to data for research. This would
improve the efficiency and quality of trauma care.
30

31. THANK YOU
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