The diaphragm attaches anteriorly and laterally to the inferior sternum, xiphoid process, lower ribs, and costal cartilage. Posterior attachments include the crura and arcuate ligaments connecting to the lumbar vertebrae. Diaphragmatic rupture often results from blunt trauma, presenting with dyspnea, chest pain, and herniated abdominal organs into the thorax seen on imaging as dependent viscera or the collar sign. Delayed presentations can lead to bowel strangulation. CT is the most sensitive imaging method to detect discontinuity of the hemidiaphragm and intrathoracic herniation of abdominal contents. Surgical repair is usually required to correct diaph

1. DIAPHRAGM

2. Drawing (view from below) shows the large central tendon, which is formed by the transverse
septum.

3. Anterior and lateral attachments
• Inferior sternum, xiphoid process, lower six ribs, and
costal cartilage.
Posterior attachments
• The two diaphragmatic crura
• The medial arcuate ligaments
• The lateral arcuate ligaments
upper lumbar vertebral
bodies
b/n the L1 or L2 VB
and the
TPs of L1.
TPs of T12 laterally to
midportion of the
12th ribs.

4. DIAPHRAGMATIC RUPTURE
• Post-traumatic laceration of hemidiaphragm, frequently
resulting in herniation of abdominal viscera into thorax.
Etiology:
• Trauma (M.C) -Blunt trauma more common than
penetrating trauma.
• Less commonly idiopathic or related to previous surgery.
Location:
• Occur more on the left.
• Clinical manifestation (visceral herniation) much more
common on left side (70-90%).

6. Morphology:
• Tears are usually >10 cm in length, are radially orientated
and occur at the weakest part of the diaphragm, the
musculotendinous junction in a posterolateral location.
• Prevalence of visceral herniation increases with larger
tears

7. • Presentation:
• Acute
• Multiple associated injuries- pelvic fractures, splenic injuries and
renal injuries
• Symptoms may be nonspecific and include dyspnea, chest pain,
shoulder pain, and cyanosis
• Diagnosis delayed when
• Often other more compelling injuries such as aortic laceration
• Intubated patient on positive pressure may prevent herniation
• Clinical diagnosis of acute diaphragm injury can be challenging.
Consequently, a high index of suspicion is required.
• Delayed/Obstructive
• In delayed presentation often Strangulation of bowel occurs

8. • Radiographic Findings• Chest radiography usually abnormal but often nonspecific
• Specific signs:
1. Air-filled viscus in hemithorax with or without focal constriction of
the viscus at the site of the tear (collar sign).
2. Tip of NG tube in hemithorax
• Abnormal diaphragmatic contour and changes in shape
with change in position.
• Elevated diaphragm > 7 cm.
• Contralateral mediastinal shift.
• Strangulation of bowel.

12. CT Findings• More specific
1.
Direct discontinuity of the hemidiaphragm- most sensitive sign of
rupture
2.
Intrathoracic herniation of abdominal contents1.
2.
left side - The stomach and colon
right side -liver
Collar sign - Visceral herniation with focal constriction of bowel or liver
3.
• Hump and Band -The hump and band signs both result from herniation of the liver
through a right-sided diaphragmatic rupture .
Dependent viscera sign is very accurate.
1.
1.
2.
Visualization of abdominal viscera against posterior chest wall.
Diaphragmatic thickening, segmental absence, and combined
hemothorax and hemoperitoneum are strong predictors of blunt
diaphragmatic rupture

16. Collar Sign or Hour Glass Sign

19. Hump and Band Sign

20. Dangling Diaphragm sign

21. Dependent Viscera Sign

22. Dependent Viscera Sign

23. Dependent Viscera Sign

25. Thickening of the Diaphragm

26. MRI:
MR imaging is less readily adapted to the acute trauma setting
and should be reserved for patients with an uncertain CT
diagnosis or delayed signs of diaphragmatic tear.
USG:
Bedside emergency ultrasonography can be safe and accurate.
But it can be compromised by pulmonary aeration, gastric and
colonic gas, subcutaneous emphysema, bandages, abdominal
pain and obesity.
Other Modalities• Barium gastrointestinal findings
Approximation and narrowing of afferent and efferent bowel loops
(pinched limbs) through the diaphragmatic defect (collar sign or kissing
birds sign).

27. Imaging Strategy
Admission supine chest radiography
CXR suggestive of a
diaphragmatic injury
CT
uncertain diagnosis after
CT
MRI

28. DIFFERENTIAL DIAGNOSIS1. Eventration of Diaphragm
• No dependent viscera sign
• Hemidiaphragm should appear intact
• No associated injuries
• Typically seen in elderly females without a history of recent trauma
2. Diaphragm Paralysis
• Paradoxical motion at fluoroscopy (sniff test)
• No recent history of trauma
3. Sub-pulmonic or loculated Pleural Effusion• No abnormally positioned air-filled bowel
• Crus intact
4. Paraesophageal Hernia
• Tear rare at esophageal hiatus.

29. Management:
• Surgical Repair