IMAGINGIN

DIAPHRAGMATIC INJURY Traumatic Diaphragmatic

Rupture TDR

Up to 90% of traumatic diaphragmatic ruptures occur in young men after motor vehicle accidents the left hemidiaphragm injury more three-four times than injuries to the right side Most common hernaited organs Stomach <small and large bowel < spleen < liver

Diaphragmatic Rupture Chest X-ray

-Intrathoracic herniation of a hollow viscus (stomach, colon, small bowel) with or without focal constriction of the viscus at the site of the tear (collar sign) -Visualization of nasogastric tube above level of left diaphragm

-Elevation of the hemidiaphragm.

-Distortion or obliteration of the outline of the hemidiaphragm.

-Contralateral shift of the mediastinum.

Nasogastric tube overlying chest on plain film ,in left thorax

DD :

Tip is still inside stomach : diaphragmatic rupture

Tip outside GIT : in bronchus or pleural space

Tube outside the patient

Intrathoracic stomach herniation

With contralat.mediastinal shift

Intrathoracic colon herniation

With contralat. Mediastinnal shift

Chest X-ray PA view

showing a heterogeneous

opacity in the left lower

zone

Barium meal examination of stomach and

intestine showing presence of loops of

intestine within the left hemithorax

Right diaphragmatic rupture

Partial herniation of stomach

into left chest

TDR

Computed Tomography:

diaphragmatic defect or discontinuity of crus or dangling

diaphragm sign .

intrathoracic herniation of abdominal contents.

The collar sign, a waist like constriction of the herniating organ at

the site of the diaphragmatic tear.

The dependent viscera sign: supine at CT study

the herniated viscera (bowel or solid organs) are no longer

supported posteriorly by the injured diaphragm and fall to a

dependent position against posterior chest wall

The collar sign dangling diaphragm sign .

Constriction of stomach

As it passes through

Diaphragmatic head

Collar sign

Torn free edge of left hemidiaphragm

dangling diaphragm sign .

The dependent viscera sign

The stomach is lying adjacent to posterior ribs instead of within confines of

normal diaphragm

Presence of bowel loops and kidney in the left hemithorax

Herniation of stomach into chest

Discontinuity of left

Hemidiaphragm with

Stomach herniation into chest

Normal patient Right hemidiaphragm tear

Diaphragmatic defect or discontinuity

Axial CT of the midthorax

Sagittal and coronal reformatted images

Post contrast axial CT scan

Coronal reformatted CT image Coronal contrast material-enhanced fat-

suppressed fast gradient-echo MR

image

Dependent sign

Axial CT image Coronal reformatted CT image

Finding suggestive of diaphragmatic tear

Sagittal single-shot fast spin-echo Coronal Gd fast gradient-echo

Post. diaphragm outlined by

hemoperitoneum+ pleural eff.

Sagittal reformatted CT image Axial CT image

Effusion

Traumatic Rupture of the Right Diaphragm duodenal contusion

diaphragmatic hematoma into the

posterior pararenal space (arrow)

posterior right rib fracture (arrow) at the

site of a diaphragmatic hematoma (black

arrowheads).

DIFFERENTIAL DIAGNOSIS

Bockdalek hernia absence of trauma morgagni hernia

Eventration

Diaphragm retains its continuity and attachment to costal margin