The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Kylee Brooks, MD, Parker Hambright, MD, Alexis Holland, MD, and William Lorenz, MD. It is has special guest editor: Kyle Cunningham, MD

1. Diaphragmatic Injuries
Kylee Brooks, MD1, Parker Hambright, MD1,
Alexis Holland, MD2, William Lorenz, MD2
Departments of Emergency Medicine1 & Surgery2
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD1 & Kyle Cunningham, MD2 Faculty Editors
CMC Imaging Mastery Project

2. Disclosures
 This presentation of the CMC Imaging Mastery Project series is proudly
sponsored by the Emergency Medicine and Surgery Residency Programs
at Carolinas Medical Center.
 The goal is to promote widespread mastery of imaging interpretation.
 There is no personal health information within, and all ages have been
changed to protect patient confidentiality.

3. Process
• Colleagues across CMC share their interesting clinical cases with us.
• Resident author teams organize cases and add up-to-date literature.
• Faculty editors provide peer-review of content for accuracy and impact.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

5. It’s All About The Anatomy!

6. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

7. Before Discussing Our Diaphragmatic Injury Cases,
Let’s Review Some Basic Principles Of Injury
Mechanism And Imaging Findings.

8. How The Mechanism Of Injury Impacts Imaging Findings
Blunt (25%)
• A blunt force is delivered to the
abdomen, causing an abrupt, transient
increase in intra-abdominal that
lacerates the diaphragm
• This force pulls the wound edges apart
and causes intra-abdominal organs to
herniate through the tear
Imaging Finding
• Hemidiaphragm elevation
• Diaphragmatic defects
• Displaced organs
Penetrating (75%)
• A foreign object causes a direct
laceration of the diaphragm
• There is typically not an abrupt increase
in intraabdominal pressure to push the
torn edges apart, create a larger defect,
or cause organ herniation.
Imaging Finding
• Signs of diaphragmatic defects or organ
displacement are rare
• Contiguous injuries above/below the
diaphragm provide an important clue
• A wound trajectory traversing the
diaphragm is diagnostic

9. Chest X-Ray Findings
Blunt Diaphragm Injury:
• Indistinct and/or elevated
hemidiaphragm
• Basilar atelectasis
• Abdominal organs in the chest
• Abnormal nasogastric tube
position

10. 53-year-old female in a car crash. Shortly after arrival the patient became combative and required intubation. A
gastric tube was placed and was found to be coiled in the stomach, that was herniated into the left chest
CXR On Arrival CXR Following Intubation & Gastric Tube Placement

11. Chest X-Ray Findings
Penetrating Diaphragm Injury:
• Chest X-ray findings may be
absent of subtle
• Ipsilateral hemothorax
• Indistinct hemidiaphragm
• Elevated hemidiaphragm

12. Penetrating Injury
The diaphragm is at risk with any
penetrating wound occurring
between:
T4 and T8: Chest/Abdomen
T4 and T12: Back

13. Case #1
46-Year-Old In A
Motor Vehicle
Crash.

14. Case #1
46-Year-Old In A
Motor Vehicle
Crash.
Elevated
Hemidiaphragm
Disarticulated
Left Rib

15. Spleen Herniated Into
The Left Chest
Viscera Herniated
Through A Large
Chest Wall Defect
Case #1
46-Year-Old In A
Motor Vehicle
Crash.

16. The Patient Also Has A Tear Of
The Descending Thoracic Aorta!
Case #1
46-Year-Old In A
Motor Vehicle
Crash.

17. 46-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: G. Sachdev, MD

18. 46-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: G. Sachdev, MD

19. 46-Year-Old With A Ruptured Left Hemidiaphragm - Repaired
*****
Courtesy: G. Sachdev, MD

20. Chest X-Ray After Diaphragm Repair And Aortic Endovascular Stenting
Case #1
46-Year-Old In A
Motor Vehicle
Crash.

21. Case #2
45-Year-Old
Male Involved In
A Roll-Over Car
Crash.

22. Case #2
45-Year-Old
Male Involved In
A Roll-Over Car
Crash.
Elevated
Hemidiaphragm

23. 45-Year-Old Car Crash Victim
Ruptured Diaphragm
Viscera Herniated
Into The Chest
Air-Fluid Level In
The Stomach (→)
That Is Above The
Diaphragm

24. 45-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: K. Cunningham, MD

25. 45-Year-Old With A Ruptured Left Hemidiaphragm
Courtesy: K. Cunningham, MD

26. Post-Operative Chest X-Ray
Case #2
46-Year-Old In A
Motor Vehicle
Crash.

27. Case #3: 16-Year-Old Sustains A Gunshot Wound To The Right Chest.

28. Case #3: 16-Year-Old Sustains A Gunshot Wound To The Right Chest.
The Chest X-Ray Demonstrates A Right Hemothorax And A Bullet Is Seen On The
Abdominal X-Ray. The eFAST Is [+] For Intra-Abdominal Free Fluid.

29. Case #3: 16-Year-Old Sustains A Gunshot Wound To The Right Chest.
Notice That The Right Diaphragm Appears Intact On The Chest X-Ray.

30. Case #3: 16-Year-Old Sustains A Gunshot Wound To The Right Chest.
Notice That The Right Diaphragm Appears Intact On The Chest X-Ray.
Exploratory Laparotomy:
Injuries to the:
• Liver
• Right kidney
• Right hemidiaphragm

31. Case #4: 30-Year-Old Sustains A Gunshot Wound To The Left Flank.

32. Case #4: 30-Year-Old Sustains A Gunshot Wound To The Left Flank.
There Is No Visible Chest Injury And A Bullet Is Seen In The Abdomen.
The FAST Is [+] Hemoperitoneum.

33. Case #4: 30-Year-Old Sustains A Gunshot Wound To The Left Flank.
Exploratory Laparotomy:
Injuries to the:
• Pancreas
• Splenic artery and view
• Stomach
• Left hemidiaphragm

34. The American Journal of Surgery 2015;209:864-869-217.
Traumatic Diaphragmatic Injury (TDI) in the American College of Surgeons
National Trauma Data Bank: A New Examination of a Rare Diagnosis
National Trauma Database 2012 review of 833,309 patients of which 3873 had TDI:
Incidence 0.46%
Penetrating 73%
Blunt 27%
Penetrating Blunt
• Gunshot wounds
• Stab wounds
67%
33%
• Motor vehicle crash
• Pedestrian stuck
63%
10%
Mortality 9% Mortality 20%
Blunt TDI More likely to have associated injuries of the thoracic aorta, lung, bladder, spleen
Penetrating TDI More likely to have associated injuries of the liver and bowel
Traumatic diaphragmatic injuries are rare, usually seen with other
significant torso injuries, and associated with significant mortality.

35. American Journal of Emergency Medicine 2017;35:214-217.
Blunt Traumatic Diaphragmatic Injury:
A Diagnostic Enigma With Potential Surgical Pitfalls
Israeli National Trauma Registry review of 354,307 blunt trauma patients 1998-2013:
Incidence 0.065%
Vehicular Trauma 84.4%
Pedestrian Struck 14.7%
Motorcycle Crash 4.3%
Mortality 26.8%
♂︎:♀ 2.5 : 1
Urgent Surgery 62%
Associated Injuries
Rib, Pelvis,
Extremity
40%
Liver, Spleen, Lung 30%
Blunt diaphragmatic injuries are rare and associated with a significant mortality
as well as a high frequency of other coincident orthopedic and visceral injuries.

36. Journal of Trauma & Acute Care Surgery 2013;74(6):1392-1398.
Presentations And Outcomes In Patients With Traumatic
Diaphragmatic Injury: A 15-Year Experience
Maryland Shock Trauma Case Series 1995-2009, [n=773]:
Mortality: Overall 21%
Mortality: Left 17%
Mortality: Right 26%
Penetrating 73%
Blunt 27%
Left 57%
Right 40%
Bilateral 3%
Factors Associated With
Increased Mortality
• Age
• Injury severity score
• Associated cardiac injury
• Right diaphragm injury
• Operative intervention
Left sided diaphragmatic injuries had a higher rate of associated
injury to the stomach, spleen, pancreas.

37. Diagnostic And Interventional Radiology 2014;20:121–128.

38. Diagnostic And Interventional Radiology 2014;20:121–128.

39. Discontinuous Diaphragm Sign
The discontinuous diaphragm sign is present if there is visualization of direct
discontinuity of the diaphragm, along with segmental non-visualization.
Diagnostic And Interventional Radiology 2014;20:121–128.

40. Dangling Diaphragm Sign
The dangling diaphragm sign is present if the free edge of the torn diaphragm is
visible, curled inward away from the chest wall towards the central abdomen.
Diagnostic And Interventional Radiology 2014;20:121–128.

41. Intrathoracic herniation of viscera is present if
intrabdominal organs are visible within the
thoracic cavity through the defect in the
diaphragm.
Diagnostic And Interventional Radiology 2014;20:121–128.
Intrathoracic
Visceral Herniation

42. Collar Sign
The collar sign, also called the hourglass sign
refers to a waist-like or collar-like appearance
of herniated organs at the level of the
diaphragm.
Diagnostic And Interventional Radiology 2014;20:121–128.

43. Dependent Viscera Sign
The dependent viscera sign is present if the liver abuts the posterior ribs on the
right, and/or if bowel abuts the ribs, or lays posterior to the spleen on the left.
Diagnostic And Interventional Radiology 2014;20:121–128.

44. Thickening Of The Diaphragm
Thickening of the diaphragm may be present at the site of
injury with or without retraction of the edges.
Diagnostic And Interventional Radiology 2014;20:121–128.

45. Contiguous Injury Across The Diaphragm
Contiguous injury across diaphragm implying transdiaphragmatic penetration,
is an indirect sign of (typically penetrating) diaphragmatic injury.
Diagnostic And Interventional Radiology 2014;20:121–128.
Hemothorax &
Lung Contusion
Liver
Laceration

46. Penetrating Trajectory Across The Diaphragm
CT images in a patient with a gunshot wound to the right chest show the injury
trajectory (across the right hemidiaphragm) traveling caudally and laterally.
Radiology (RSNA) 2013;268:729-737.

47. Diagnostic And Interventional Radiology 2014;20:121–128.

48. Diagnostic And Interventional Radiology 2014;20:121–128.

49. Diagnostic And Interventional Radiology 2014;20:121–128.

50. Journal of Trauma: Injury, Infection & Critical Care, 2007;63:538-543.
Accuracy of Computed Tomography (CT) Scan in the Detection of Penetrating
Diaphragmatic Injury
Objective
To accuracy of CT scan (in identifying diaphragmatic injuries in patients with penetrating torso
trauma.
Methods
Single-center retrospective review of 803 consecutive patients with penetrating torso trauma
over a four-year period. CT results are classified as positive [P], negative [N], or equivocal [Eq].
Results
Mechanism was gunshot wounds (36%) and stab wound (64%). Injury was detected in 67 (8.3%).
Rule Out Injury ([P + Eq] vs. N) Sensitivity: 94% Specificity: 95.9%
Rule In Injury (P vs. [N + Eq]) Sensitivity: 82.1% Specificity: 99.7%
MDCT scan is an accurate test to detect diaphragm injury. When MDCT is
equivocal, further investigation is required to evaluate the diaphragm.

51. Emergency Radiology 2023;30:765–767.
Diagnostic Utility of Multidetector CT Scan in Penetrating Diaphragmatic Injuries:
A Systematic Review and Meta-Analysis
Objective
To explore the diagnostic utility of multidetector CT scan (MDCT) in identifying diaphragmatic
injuries in patients with penetrating trauma.
Methods
Systematic review and meta-analysis of nine articles that included 294 patients with confirmed
penetrating diaphragmatic injuries.
MDCT Scan Finding Evaluated: herniation of viscera or fat into the thorax, the collar sign, dependent
viscera sign, transdiaphragmatic trajectory, diaphragmatic discontinuity, and diaphragmatic thickening.
Results
Pooled Sensitivity: 74% (95% CI: 56%-87%) Pooled Specificity: 92% (95% CI: 79%-97%)
Findings on MDCT are highly specific but only moderately sensitive for penetrating TDI.
If your diagnostic suspicion is high and the CT is [-], further evaluation is essential.

52. Surgical Endoscope 2015;29:747-752.
Laparoscopy In The Diagnosis And Repair Of Diaphragmatic Injuries In Left-Sided
Penetrating Thoracoabdominal Trauma
Objective
To evaluate the effectiveness of laparoscopy in the diagnosis and repair of diaphragmatic injuries
in patients with penetrating left-sided thoracoabdominal trauma.
Methods
Prospective, single-center study of 55 stable adult patients.
Results
• The median age was 26.3 years with a 10:1 ♂︎:♀ratio. 98% sustained stab wounds.
• There were 22 (40%) diaphragmatic injuries; 95% were successfully repaired laparoscopically.
• Twenty six (47%) patients had radiographic findings of which 10 (38%) had injuries.
Conclusion
In this population imaging was insensitive for penetrating diaphragmatic injuries. Laparoscopy
visualized 100% of injuries, and was effective at repairing 21/22 (95%) of them.

53. Journal of Trauma & Acute Care Surgery 2018;85:198–207.
Evaluation and Management of Traumatic Diaphragmatic Injuries: A Practice
Management Guideline From the Eastern Association for the Surgery of Trauma
SUMMARY Of 2018 EAST Practice Management Guidelines
#1 In stable patients with left thoracoabdominal stab wounds, laparoscopy is recommended
rather than CT imaging to decrease the incidence of missed diaphragm injuries.
#2 In stable patients with confirmed or suspected penetrating injuries of the right diaphragm,
non-operative management is recommended over operative management.
#3 In stable patients with acute diaphragm injuries, the abdominal rather than the thoracic
approach is preferred for injury repair.
#4 In patients with acute penetrating diaphragm injuries without concerns for other
intraabdominal injuries, laparoscopic repair is recommended over open repair.

54. Journal of Trauma & Acute Care Surgery 2018;85:198–207.

55. More Diaphragmatic Injury Cases From
Carolinas Medical Center

56. Case #5: 45-Year-Old In A Car Crash
Ruptured Right Hemidiaphragm Collar Sign (→ ←)

57. Case #6: 21-Year-Old Sustaining Two Gunshot Wounds To The Right Chest
Exploratory Laparotomy: Injuries Of The Right Diaphragm, Liver, Stomach, Spleen, Small Bowel

58. Case #7: 65-Year-Old In A High-Speed Car Crash
Ruptured Left Hemidiaphragm
Collar Sign (→ ←)

59. Case #8: 38-Year-Old Pedestrian Struck
Ruptured Left Hemidiaphragm
Clavicle Fracture
Tracheal
Deviation
Elevated
Hemidiaphragm

60. Key CT Findings
• Stomach herniated
into the chest (*)
• Discontinuous
diaphragm sign (→)
*
*
*
Case #8: 38-Year-Old Pedestrian Struck

61. *
*
*
Case #9: 13-Year-Old Car Crash
Ruptured Left Hemidiaphragm
Stomach In The Chest

62. Key Points
• Diaphragmatic injuries are rare, occurring in <1% of injured patients
• 75% of diaphragmatic injuries are penetrating and 25% are blunt
• Because of the protection provided by the liver on the right, 57% of
diaphragmatic injuries occur on the left
• Associated thoracoabdominal injuries are common

63. Key Points
• Because blunt and penetrating diaphragmatic injuries are the results of
different energy forces, each have unique imaging findings
• Imaging finding in blunt diaphragmatic injuries reflect hemidiaphragm
elevation, diaphragmatic defects, and displaced organs
• Imaging findings in penetrating diaphragmatic injuries are rare.
Contiguous injuries above/below the diaphragm provide an important
clue, and a radiographic wound trajectory traversing the diaphragm is
diagnostic

64. • CT imaging is sensitive and specific for blunt diaphragmatic injuries
• CT is specific but not sensitive for penetrating diaphragmatic injuries. When injury is
suspected diagnostic laparoscopy is recommended

65. References:
Traumatic Diaphragmatic Injury in the American College of Surgeons National Trauma Data Bank: A New
Examination of a Rare Diagnosis. The American Journal of Surgery 2015;209:864-869-217.
Blunt Traumatic Diaphragmatic Injury: A Diagnostic Enigma With Potential Surgical Pitfalls. American Journal of
Emergency Medicine 2017;35:214-217.
Presentations And Outcomes In Patients With Traumatic Diaphragmatic Injury: A 15-Year Experience. Journal of
Trauma & Acute Care Surgery 2013;74(6):1392-1398.
Traumatic Diaphragmatic Injury: A review of CT Signs and the Difference Between Blunt and Penetrating Injury.
Diagnostic and Interventional Radiology 2014;20:121-128.
Accuracy of Computed Tomography (CT) Scan in the Detection of Penetrating Diaphragmatic Injury. Journal of
Trauma: Injury, Infection & Critical Care 2007;63:538-543.
Diagnostic Utility of Multidetector CT Scan in Penetrating Diaphragmatic Injuries: A Systematic Review and Meta-
Analysis. Emergency Radiology 2023;30:765–767.

66. References:
Penetrating Diaphragmatic injury: Accuracy of 64-Section Multidetector CT with Trajectography. Radiology RSNA 2013;268(3)
729-737.
Laparoscopy In The Diagnosis And Repair Of Diaphragmatic Injuries In Left-Sided Penetrating Thoracoabdominal
Trauma. Surgical Endoscopy Surgical Endoscope 2015;29:747-752.
Evaluation and Management of Traumatic Diaphragmatic Injuries: A Practice Management Guideline from the
Eastern Association for the Surgery of Trauma. Journal of Trauma & Acute Care Surgery 2018;85:198–207.

67. Thank you!