Blunt diaphragmatic injury is often caused by sudden deformation of the lower thoracic cage where the diaphragm is anchored, coupled with a rapid increase in the pressure gradient between the thoracic and abdominal cavities, resulting in diaphragm rupture. Traffic accidents and falls from height are frequent causes of blunt diaphragmatic injuries. Approximately 90% of these injuries occur on the left side, possibly due to the liver in the right upper abdomen mitigating the force of impact and the directional influence of automobile seat belts.
Ruptures of the diaphragm resulting from blunt trauma often involve large tears, commonly located at the central tendon or peripheral attachments of the diaphragm. Abdominal organs can easily herniate into the thoracic cavity through the diaphragmatic tear. Common herniated organs include the stomach, spleen, colon, small intestine, and liver. Patients with severe blunt-force diaphragmatic injuries often present with associated contusions or lacerations of thoracic or abdominal organs, along with injuries to multiple other areas such as the head, spine, pelvis, and extremities.
Hemothorax or pneumothorax, coupled with herniated abdominal organs in the thoracic cavity, may compress the lungs and shift the mediastinum, leading to respiratory distress. Clinical findings in such cases often include reduced breath sounds on the affected side, dullness or tympanic sounds on percussion, and mediastinal displacement. Strangulation or incarceration of herniated abdominal organs may result in manifestations of intestinal obstruction or peritonitis, such as abdominal pain, vomiting, abdominal distension, and peritoneal irritation signs. Of note, diaphragmatic ruptures may initially be difficult to diagnose, as both clinical signs and chest X-rays lack specificity. Computed tomography (CT) scans are helpful in confirming the diagnosis. Because air and contrast entering the bowel can convert partial obstruction of herniated intestinal loops into complete obstruction, double-contrast studies of barium and air in the intestine are generally contraindicated. For cases of traumatic diaphragmatic hernia, thoracentesis or closed thoracic drainage should be performed cautiously to avoid injury to herniated abdominal organs. Additionally, pneumatic antishock garments should not be applied in cases of suspected traumatic diaphragmatic hernia, as they may increase intra-abdominal pressure.
When traumatic diaphragmatic rupture or diaphragmatic hernia is diagnosed, prompt surgical exploration and diaphragmatic repair are needed. The surgical approach can be thoracic, abdominal, or a combined thoracoabdominal route, depending on the specific nature of the injury. Surgeons should be prepared with surgical plans for different approaches. Careful exploration of thoracic and abdominal cavity organs is necessary, with appropriate treatment administered for any associated injuries. Repair of the diaphragmatic tear should be performed, with evacuation of accumulated blood and fluids from the thoracic and abdominal cavities. Chest and abdominal drains should then be placed.