Penetrating diaphragmatic injuries can result from penetrating trauma to the lower chest or upper abdomen. When penetrating forces simultaneously injure thoracic and abdominal organs along with the diaphragm, such injuries are classified based on the entry point of the object: injuries with entry wounds in the chest are termed thoracoabdominal injuries, while those with entry wounds in the abdomen are termed abdominothoracic injuries. Commonly injured thoracic organs include the lungs and heart. On the right side of the abdomen, the liver is frequently involved, while on the left side, the spleen is often affected, followed by the stomach, colon, small intestine, and others. High-velocity projectile injuries, characterized by significant kinetic energy and penetrating force, often result in through-and-through wounds, sometimes causing multiple perforations in the dome-shaped diaphragm. Sharp instruments, in contrast, typically produce blind tract injuries. Isolated diaphragmatic injuries from penetrating trauma are relatively uncommon.
In addition to significant bleeding at the wound site and clinical manifestations such as hemorrhagic shock, patients with thoracoabdominal or abdominothoracic injuries often present with concurrent hemothorax, hemopneumothorax, hemopericardium, intra-abdominal hemorrhage, pneumoperitoneum, or signs of peritonitis caused by perforation of hollow viscera. Bedside ultrasound provides rapid and accurate assessment of hemothorax, hemopericardium, intra-abdominal hemorrhage, and solid organ injuries. Thoracentesis and paracentesis serve as simple yet effective methods to confirm hemothorax or hemoperitoneum. For stable patients, chest and abdominal X-rays or CT scans can help identify hemopneumothorax, hemopericardium, herniation of abdominal organs into the thoracic cavity, subdiaphragmatic free air, intra-abdominal hemorrhage, organ injuries, and retained metallic foreign bodies. However, these imaging studies require time and patient transport, necessitating caution in critically injured cases.
Emergency surgical intervention is mandatory for penetrating diaphragmatic injuries. Initial management prioritizes addressing thoracic wounds and tension pneumothorax, evaluating for cardiac tamponade or major vascular injuries, and actively correcting shock while controlling hemorrhage. Surgical approach—trans-thoracic, trans-abdominal, or combined—is determined by injury patterns and clinical presentation. A thorough exploration of thoracic and abdominal organs is performed, followed by repair of damaged structures, including the diaphragm.