RUPTUR DIAFRAGMA

1. Diagnostic and Management of Diaphragmatic Rupture in
Emergency Room:
A Case Report of 67 Years Old Woman at Sanglah Hospital, Bali.
By :
dr. Krishna Murprayana
Mentor :
dr. Ketut Sudiasa, Sp.B(K)Trauma, FINACS

2. Introduction: The prevalence of diaphragmatic rupture is 5% of all cases of blunt
abdominal trauma.
Case Report: We report a case of 67 years old woman brought to Emergency Room at
Sanglah Hospital prior to motorbike accident. Her chief complaints were upper
abdominal pain and shortness of breath. We found that she had multiple bruises on her
thorax and abdomen. Bowel sound was heard on auscultation of left base pulmonary 
emergency exploratory laparotomy was conducted to repair the diaphragm, but during
the surgery we found another internal organ injuries.
Discussion: Comparing the real case we found with literatures, this patient came with
acute phase of diaphragm rupture accompanied with others abdominal organ traumas.
Cito laparotomy surgery was successfully done to repair the diaphragm.
Conclusion: Diaphragmatic rupture should be suspected in all patients with trauma,
especially if they have blunt trauma to the abdomen and waist on the lateral part 
Surgery is a mandatory action to repair the diaphragm.
Abstract

3. Diaphragmatic trauma
Introduction
• Caused by blunt or penetrating thoracoabdominal trauma.
• Incidence ranges from 0.8 to 15% of all traumas
Diaphragmatic rupture
• Tear of the diaphragm, the muscles at the bottom of the
thoracic cavity.
• Prevalence 5% of all cases of blunt trauma
• More common on the left side : right side  ratio of 3:1
tearing due to excessive stretching of the diaphragm, transmission of forces
that occur at the point, and avulsion of the diaphragm attachment
common
etiology
Ernest E.M., Kevin M.S., et al. Trauma Textbook 8th Edition: Diaphragm. 2017; 28: 539-48.
Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg 1974;128: 17.
Rizky Amaliah. Diagnosis dan Tatalaksana Ruptur Diafragma pada Fase Akut dan Fase Laten. Jurnal Bedah Nasional.
2020; Vol.4(1) 26-36.

4. ● The diagnostic phase of
diaphragmatic rupture often
delayed
● Thoracoabdominal trauma in
Indonesia is mainly caused by traffic
accidents in form of multiple
traumas.
● Multiple traumas  many focuses
of initial assessment at emergency
room  predisposing factor for late
diagnosed and treated.
Introduction
Mechanism Number of
patients with
diaphragm
injury
Percentage
Blunt 3.585 15%
Penetrating 4.788 20%
Other 99 0.0%
Unspecified 1.656 7%
Total 10.128 43%
lundgren J, Mousavie S., et al. A review on Traumatic Diaphragmatic Rupture. Trauma Emergency Care. 2017; Vol.
2(5): 1-4.
Heru S.K., Nengah Kuning A., Ketut Wiargitha., Late Diagnosis of Traumatic Diaphragmatic Rupture: Experience in
Developing Country. Cermin Dunia Kedokteran. 2020; Vol. 47 (12).
Ashraf Fawzy, et al. Rupture Diaphragm: Early Diagnosis and Management. Journal of the Egyptian Society of
Cardio-Thoracic Surgery. 2017; Vol. 25 (2).

5. Case Report
Identity
A 67-year-old woman was
brought to the emergency room
of Sanglah Hospital
Present History
Complaining of abdominal pain
that was felt predominantly in
the upper left abdomen and
followed by shortness of breath
Mechanism of Injury
motorbike accident  she hit a
running dog while riding a
motorcycle so she fell from her
motorbike with her chest hit the
motorbike then fell to the
asphalt in a prone position

6. She was well aware without
any orientation disturbance,
Case Report
• A : clear airway,
• B : spontaneous breathing
• C : stable circulation.
VITAL SIGN
• BP : 100/70 mmHg
• HR : reg, 98 times per minute,
• RR : reg, 32 times per minute.
• SpO2 : 95% in room air  99% by 10 lpm face
mask oxygenation,
• TAX : 36.2.
Conciousness Primary survey

7. Physical Examination
R Thorax
Inspection :
Bruises (+) along the right lateral
hemithorax of the patient , bilateral chest
movements was symmetrically
Auscultation :
Decrease in breath sounds in the left lung
base accompanied by bowel sounds.
Percussion :
Dullness in left basal regio
Palpation :
Vocal fremitus within normal limit
Pain in bruises area with palpation
Case Report
R Abdomen
Inspection :
Bruises (+) in right upper quadrant
Auscultation :
Normal bowel sound
Percussion :
Within normal limit
Palpation :
Tenderness when palpated in the right
and left upper quadrant regions

8. Clinical Pics

9. Laboratory results showed slightly leucocytosis (12.3
g/dl) accompanied by mild anemia (9.3 g/dl) and
decreased thrombocyte (149 g/dl).
Case Report
Supporting Examination
Thorax and shoulder x-ray
• there was consolidation in the middle zone of the
left lung and the lower zone of the right lung
suspected of a pulmonary contusion.
• appearance of abdominal viscera
• There was also fracture of lateral 1/3rd left clavicle, a
complete non-displaced fracture of the 4th and 5th
right lateral costae and a fracture of the lateral margin
of the right scapula with soft tissue swelling around it.

10. 1. Blunt thoracal and abdominal
trauma suspected left
diaphragm rupture,
2. closed fracture of lateral 1/3rd left
clavicle,
3. complete non-displaced fracture of
the 4th and 5th right lateral costae.
Diagnosis

11. Emergency exploratory laparotomy, found :
● Rupture of zone II liver grade II, rupture of the left
posterior diaphragm about 6 cm (grade III)
● Diaphragm and colon ascending repaired with
primary intermittent suture.
● Insertion of sub-hepatic and left thorax drain were
done.
Case Report

12. Case Report

13. Discussion
Blood supply to diaphragm comes from several
arteries :
• superior surface of diaphragm is supplied
by the musculophrenic artery,
pericardiachophrenic a., and superior
epigastric a
• inferior surface of diaphragm is supplied
by inferior phrenic a
Diaphragm is innervated by phrenic nerves
originating from the fourth cervical nerve root,
with contributions from the third and fifth
cervical nerve roots
Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg 1974;128: 17.

14. Discussion
The elliptical shape of diaphragm
conforms to the thorax, which
also affects its function and
determines its anatomical
structure.
When the diaphragm moves on
quiet inspiration, there is a
change in intrathoracic volume of
up to 75%.  during deep
inspiration, the movement
distance is 1.5 cm to 7 cm.
The incidence of diaphragmatic rupture
is more common in men with an
incidence rate of almost 4 times more
than in women, and it is also found that
the most common cases are in men with
the 4th decade of age
main cause of diaphragmatic rupture
is blunt trauma which up to 80% of
cases, followed by falls from a height
(10%) and sharp trauma (10%).
lundgren J, Mousavie S., et al. A review on Traumatic Diaphragmatic Rupture. Trauma Emergency Care. 2017; Vol. 2(5): 1-4.
Heru S.K., Nengah Kuning A., Ketut Wiargitha., Late Diagnosis of Traumatic Diaphragmatic Rupture: Experience in Developing Country. Cermin Dunia Kedokteran. 2020; Vol. 47 (12).

15. Acute Phase Laten Phase Obstructive Phase
This phase happened since the time
of trauma until there are obvious
signs of trauma.
• Abdominal pain,
• Other disorders due to trauma
(abdominal and thoracic walls,
pelvis, head, extremities,
hemopneumothorax, abdominal
visceral organs),
• Hemodynamic instability
• Respiratory distress
• Reduced air intake on the affected
side,
• Bowel sounds heard on chest
auscultation (pathognomonic),
• Abnormalities on plain chest X-ray,
• Defect identified during emergency
surgery (laparotomy).
This phase occurs when intra-
abdominal organs pass through the
defect and enter the thoracic cavity
and can be happened a few hours until
weeks after trauma. This reduces the
functional capacity of the thorax.
• Pain in the upper abdomen
• Dyspnoea and cyanosis
• Tachycardia
• Substernal pain or referred pain to the
shoulder
• Dyspnoea exacerbated by lying down
• Dim percussion and decreased breath
sound on the affected side
• Bowel sounds heard on chest
auscultation
• Abnormalities on plain chest X-ray
This phase happened a few months until
years after trauma when the viscera that
has a hernia shows obstruction and
strangulation.
• Nausea and vomiting
• Symptoms of intestinal obstruction or
• Ischemia and bleeding
• Chronic respiratory disorders
due to atelectasis and pneumonitis
• Mediastinal shift
• Borchardt's triad is pain
upper abdomen and distension, vomiting
and unable to insert NGT
Bowel sounds are heard on chest
auscultation
Grimes’ Classification of Diaphragm Rupture

16. Discussion
more common left sided than right because of the protective
effect of the liver
The damage more than 10 cm and occurs in the posterolateral part,
because anatomically this location is a weak pleuroperitoneal
membrane that will be traumatized
Delayed diagnostics  patients with diaphragmatic rupture almost
always come with multiple trauma conditions where other trauma
conditions mask the symptoms and clinically experienced
diaphragmatic rupture
Rizky Amaliah. Diagnosis dan Tatalaksana Ruptur Diafragma pada Fase Akut dan Fase Laten. Jurnal Bedah Nasional. 2020; Vol.4(1) 26-36.
Ashraf Fawzy, et al. Rupture Diaphragm: Early Diagnosis and Management. Journal of the Egyptian Society of Cardio-Thoracic Surgery. 2017; Vol. 25 (2).

17. ● In this case : The initial suspicion of diaphragmatic
rupture was raised during a thoracoabdominal
physical examination : bowel sounds were heard at
the left lung bases
● Chest x-ray : it has been confirmed that there is a
diaphragmatic rupture in this patient without the need
for additional CT scan.
● Specific signs that may be found on a chest x-ray :
diaphragmatic rupture occurs are the presence of an
abdominal viscera or nasogastric tube in the chest
region, a "collar sign"  non-defined diaphragmatic
boundaries, contralateral mediastinal shift, lower lobe
atelectasis, and pleural effusion
Discussion
Heru S.K., Nengah Kuning A., Ketut Wiargitha., Late Diagnosis of Traumatic Diaphragmatic Rupture: Experience
in Developing Country. Cermin Dunia Kedokteran. 2020; Vol. 47 (12).
Richard Yan. Gambaran Radiologi Konvensional pada Kelainan Diafragma. Universitas Kristen Indonesia, 2019.

18. ● The diagnostic accuracy of chest x-ray 
four times better on the left side than on
the right side.
● Chest x-ray had a sensitivity of 27-73% 
increased by 8-25% with serial chest x-
rays performed in the first 24 hours
● FAST  This examination takes time and
tends to be operator dependent but can
look for herniated viscera, or flaps from
diaphragmatic rupture.
● The diagnostic accuracy of diaphragmatic
rupture in the emergency situation using
ultrasound is 26%
Discussion
Grade Injury
I Contusion
II Laceration < 2 cm
III Laceration 2 – 10 cm
IV Laceration > 10 cm with tissue
loss < 25 cm2
V Laceration with tissue loss > 25
cm
Table 3. Grading of Diaphragmatic Injuries1
Heru S.K., Nengah Kuning A., Ketut Wiargitha., Late Diagnosis of Traumatic Diaphragmatic Rupture: Experience in Developing Country. Cermin Dunia Kedokteran. 2020; Vol. 47 (12).
Richard Yan. Gambaran Radiologi Konvensional pada Kelainan Diafragma. Universitas Kristen Indonesia, 2019.

19. Discussion
• The surgical approach options for diaphragmatic rupture
are laparoscopy, thoracoscopy, laparotomy and
thoracotomy.
• Best surgical approach must be specific to each patient's
condition.
• If trauma or abnormalities in the abdominal organs : it is
better to approach through the abdomen.
Rizky Amaliah. Diagnosis dan Tatalaksana Ruptur Diafragma pada Fase Akut dan Fase Laten. Jurnal Bedah Nasional. 2020; Vol.4(1) 26-36.
Ashraf Fawzy, et al. Rupture Diaphragm: Early Diagnosis and Management. Journal of the Egyptian Society of Cardio-Thoracic Surgery. 2017; Vol. 25 (2).
Morgan BS, Watcyn-Jones T, Garner JP. Traumatic Diaphragmatic Injury. JR Army Med Corps. 2010; 156: 139-49.

20. Conclusion
● Diaphragmatic rupture should be suspected
in all patients with trauma; blunt trauma to
the abdomen and waist on the lateral part.
● Clinical examination coupled with a chest x-
ray should be performed in a patient
suspected of having a ruptured diaphragm.
● Surgery is a mandatory action to repair the
diaphragm.  approach : laparotomy,
thoracotomy, laparoscopy and VATS
depending on the acute or latent case,
stable or unstable patient condition, other
organ abnormalities, and operator
experience.

21. Thank You