Imaging of Diaphragmatic Injury: A Diagnostic Challenge?

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50 YOM blunt trauma by traffic accidence one
month ago
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Unilateral Diaphragmatic Elevation

• 1.Subpulmonic pleural effusion
• dome of pseudodiaphragm migrates toward
  the costophrenic angle and flattens
• 2.Altered pulmonary volume
• (a)Atelectasis
• associated pulmonary density
• (b)Postoperative lobectomy / pneumonectomy
• rib defects, metallic sutures
• (c)Hypoplastic lung
• small hemithorax (more often on the
  right), crowding of ribs, mediastinal shift,
  absent / small pulmonary artery, frequently
  associated with dextrocardia anomalous
  pulmonary venous return

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• 3.Phrenic nerve paralysis
• (a)Primary lung tumor
• (b)Malignant mediastinal tumor
• (c)Iatrogenic
• (d)Idiopathic
• paradoxic motion on fluoroscopy
  (patient in lateral position sniffing)
• 4.Abdominal disease
• (a)Subphrenic abscess history of surgery,
  accompanied by pleural effusion
• (b)Distended stomach / colon
• (c)Interposition of colon
• (d)Liver mass (tumor, echinococcal cyst,
  abscess)
• 5.Diaphragmatic hernia
• 6.Eventration of diaphragm
• 7.Traumatic rupture of diaphragm
• Associated with rib fractures, pulmonary
  contusion, hemothorax
• 8.Diaphragmatic tumor
• Mesothelioma, fibroma, lipoma, lymphoma,
  metastases

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Imaging of Diaphragmatic Injury A Diagnostic
Challenge?

• S. Iochum, T Ludig, F Walter, H Sebbag, G
  Grosdidier, and AG BlumRadioGraphics 2002 22
  103S
• ??? ???

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Anatomy

• Central tendon
• Crus
• Hiatus3
• Celiac trunk
• Inf. Phrenic n.

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• type 1 configuration(48). The anterior component
  is concave posteriorly and continuous with the
  anterolateral diaphragmatic fibers (arrowheads).
• type 2 configuration(28). The anterior muscle
  fibers appear to be oriented at an angle in
  relation to the lateral fibers with midline
  discontinuity (arrowhead).
• type 3 configuration(11). The anterior muscle
  fibers lie anteriorly within a single plane.

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• CT scan shows that the diaphragm is not well
  demonstrated due to the proximity of the liver,
  which has the same attenuation. Note the
  diaphragmatic slips that attach to the ribs
  (arrowheads).
• The coronal and sagittal planes are better than
  axial planes in analysis of the diaphragm.

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Mechanisms of Injuries

• Traumatic diaphragmatic injuries occur in 0.8