Diaphragmatic Rupture

  • Etiology: blunt abdominal trauma due to increase in intraabdominal or intrathoracic pressure with tear typically being large and in posterolateral hemidiaphragm which is site of embryonic fusion, iatrogenic injury during thoracic or abdominal surgery
  • CXR: lower chest arch-like soft tissue opacity / unusual density / gas bubbles, atelectasis, pleural effusion, mediastinal shift, nasogastric tube in chest, herniated abdominal organs in chest
  • CT: collar sign with waist-like constriction of herniated viscera, dependent viscera sign of abdominal viscera faling dependently in posterior chest, blood on both sides of diaphragm without obvious abdominal injury
  • Imaging: inability to trace hemidiaphragm, elevation of hemidiaphragm, intrathoracic herniation of stomach / colon (most common on left) or liver (most common on right)
  • Clinical: left > right due to protective effect of liver, often not recognized at time of trauma

Cases of Diaphragmatic Rupture

CXR and CT and Tc-99m sulfur colloid scan of diaphragmatic rupture
CXR AP shows a left-sided large pleural nodule just beneath the clavicle. Axial CT with contrast of the chest shows multiple pleural nodules throughout the left hemithorax and absence of the spleen. Tc-99m sulfur-colloid scan shows normal radiotracer uptake in the liver with no uptake in the region of the spleen (lower left), and nodular uptake throughout the left hemithorax (lower middle) and abdomen (lower right).
CXR and upper GI of iatrogenic surgically created diaphragmatic hernia
Post-operative CXR AP (above) shows complete opacification of the left hemithorax with an air-fluid level within it. AP (lower left) and lateral (lower right) images from an upper GI exam shows herniation of the fundus of the stomach into the left hemithorax.