ClinicalRadiology (1990) 42, 97-101
Rupture of the Right Hemidiaphragm Following Blunt Trauma: The Use of Ultrasound in Diagnosis J. M. sOMERS, F. V. GLEESON and C. D. R. F L O W E R Department of Diagnostic Radiology, Addenbrooke's Hospital, Cambridge Diaphragmatic rupture occurs in approximately 5% of patients who sustain multiple trauma and post-mortem studies suggest that right-sided rupture is more common than generally realized. Four cases of rupture of the right hemidiaphragm secondary to blunt trauma are presented. The chest radiographs were all similar, demonstrating a right sided fluid collection and right lower lobe consolidation in all patients. No patient had a pneumothorax. CT was useful only in retrospect, demonstrating a posterior eventration of the liver into the thorax in two patients. Ultrasound proved diagnostic in all cases demonstrating either the free edge of the diaphragm as a flap within the pleural fluid or the liver herniating into the thorax. The value of ultrasound as a simple, non-invasive and direct means of imaging the diaphragm is emphasized. Somers, J.M., Gleeson, F.V. & Flower, C.D.R. (1990). Clinical Radiology 42, 97-101. Rupture of the Right Hemidiaphragm Following Blunt Trauma: The Use of Ultrasound in Diagnosis
Rupture of the diaphragm occurs in approximately 5 % of patients sustaining multiple injuries, and the diagnosis is often delayed with serious consequences (Bekassy et al., 1972; Hegarty et al., 1978; Estrera et al., 1979). The radiographic criteria for the diagnosis of rupture of the left hemidiaphragm, both at the time of injury and when ddayed, have been well described (Hegarty et al., 1978; Heiberg et al., 1980; Aronoff et al., 1982; Ball et al., 1982; Ammann et al., 1983; Perlman et al., 1984; Aronchick et al., 1988). Post-mortem studies, demonstrating an equal distribution of left and right-sided diaphragmatic rupture, suggest that rupture of the right hemidiaphragm is probably underdiagnosed (Estrera et al., 1979). We present our experience of four patients seen over a period of 3 years following road traffic accidents, in whom the diagnosis of rupture of the right hemidiaphragm was made within 24 hours of injury using ultrasound (US). The value of the chest radiograph and computed tomography (CT) is discussed. PATIENTS AND M E T H O D S Between June 1986 and May 1989 four adult male patients (aged 18-47 years) were admitted to Addenbrooke's or Papworth hospitals following blunt right sided chest and abdominal trauma sustained in road traffic accidents. Table 1 outlines the clinical presentation, injuries sustained, early investigations performed and clinical OUtcome. All four patients had frontal chest radiographs (one supine and three erect), on admission to hospital. Patients A, C and D underwent computed tomography of the chest and abdomen to evaluate the extent of injury to major vessels and viscera. Eight millimetre thick slices Wereobtained at 1.5 cm intervals, before and after bolus Correspondenceto: Dr C. D. R. Flower,Department of Diagnostic R~ology, Addenbrooke's Hospital, Hills Road, Cambridge CB2
intravenous contrast enhancement, through the mediastinum and or upper abdomen, using a Siemen's Somaton II machine. All four patients had US examinations of the chest and upper abdomen either before or immediately "after CT. Patients A and B were examined using a Siemens Sonoline SX with a 3.5 MHz sector transducer. Patients C and D were examined using an Eloka Echo camera SSD 650, using a 3.5 MHz linear array transducer. RESULTS Chest Radiograph
Three patients (A, B and D) had erect frontal radiographs on admission; because of the severity of his injuries a supine chest radiograph was performed on patient C. All showed similar features: 1 No rib fractures were evident on the chest radiograph, although fractures of the lower ribs were seen subsequently on a control film performed as part of an intravenous urogram (Patient A) and at CT (Patient C) 2 All patients had haemothoraces confirmed by ultrasound and drained by pleural intubation. In two patients the fluid was subpulmonary simulating a high right hemidiaphragm (Fig. 1). 3 All patients had right basal pulmonary consolidation. Computed Tomography
The diagnosis of rupture of the right hemidiaphragm was not made on the basis of the CT appearances at the time of the examination in any patient. However, on review, features suggesting this diagnosis were noted in patients A and C. In normal subjects, when scanning at the level o f the diaphragm, the liver appears in the anterior half of the right hemithorax on the most cephalad scan, and then extends posteriorly on more caudal scums. The appearance in two of our patients was quite different (Fig. 2): the diaphragm first appears in the posterior half of the hemithorax and extends anteriorly
98
CLINICAL RADIOLOGY
Table 1 - Summary of clinical presentation, management and outcome
Patient
Age
Sex
Nature of trauma
Associated injuries
Management
Outcome
A
26
M
Driver-impact from driver's side
Right haemothorax Fractures to right 10th and 1 lth ribs Right lung contusion Soft tissue contusion
Conservative
Well on discharge at 12 days
B
18
M
Driver-impact from driver's side
Right haemothorax Liver laceration
Surgical repair of liver and diaphragm
Well on discharge at 11 days
C
32
M
Driver-changing tyre on hard shoulder of motorway. Hit from right side.
Bilateral haemothoraces Crush fractures T4, T5, T6 Multiple rib fractures Lacerated liver and spleen Segmental infarct right kidney
Splenectomy Repair of liver Right hemidiaphragm not repaired
Moderate hypertension on discharge at 6 weeks
D
47
M
Driver-impact driver's side
Right haemothorax Tear in small bowel mesentery
Repair of mesentery Repair of diaphragm Dialysis for acute tubular necrosis
Well with normal renal function on discharge
Fig. 1 - Chest radiograph in patient A showing an apparent elevation of the right hemidiaphragm with a lateral peak, suggesting sub-pulmonary fluid. Note the lack of obvious trauma to the rib cage, lung or mediastinum - a feature noted in all four patients.
(a)
on subsequent caudal scans. In the third patient the CT appearance was similar to the normal situation except that the liver was elevated into the chest. The appearance of the diaphragmatic crura was normal in all three cases, and the diaphragm itself could not be distinguished as a separate structure. Ul~asound
In all four patients the diagnosis of rupture of the right hemidiaphragm was made with confidence on the basis of the ultrasound findings. In all patients the defect resulting from the diaphragmatic tear was clearly visible and in two patients the torn free edge could be seen flapping within a fluid collection which extended from the 'bare' surface of the liver to the pleural space beneath the lung (Figs 3 and 4). In two patients the free edge of the torn diaphragm was not identified but liver could be seen herniating through the diaphragmatic defect (Fig. 5). In one of these cases (patient C) the ultrasound diagnosis of rupture was made shortlY after a large haemothorax had been partially
(b) Fig. 2 - Consecutive CT slices in patient C. The liver (L) is in an elevated position and first appears in the posterior aspect of the hemithorax (a) and extends anteriorly on subsequent slices (b). Similar appearances were demonstrated in patient A.
RUPTURE OF THE RIGHT HEMIDIAPHRAGM FOLLOWING BLUNT TRAUMA
99
Table 2 - The U S appearances of rupture of the fight hemidiaphragm
patient
Liver
Freefluid
Diaphragm
A
Displaced upwards into the axilla
Subpulmonary and subdiaphragmatic
'Flapping' free edge of the diaphragm with a visible defect over the dome (Fig. 3)
B
Displaced upwards into the axilla ,m
Subpulmonary and subdiaphragmatic
'Flapping' free edge of the diaphragm with a visible defect over the dome (Fig. 4)
C
Displaced upwards with herniation through the diaphragmatic defect
Subpulmonary only
Defect over posterior aspect of the dome with herniation of 'bare' liver (Fig. 5)
D
Displaced upwards into the axilla
Subpulmonary and over 'bare' area of liver posteriorly
Only a small portion of the anterior aspect of the diaphragm visible with an extensive 'bare' area of liver posteriorly
Fig. 4 - Oblique ultrasound scan of patient B. Similar appearance to that in Fig. 3 with the free torn edge of the diaphragm ( D ~ ) clearly seen.
Fig. 3 - Longitudinal ultrasound scan of patient A. The diaphragm anteriorly and posteriorly is demonstrated (D~). Note the anterior aspect is free and could be seen 'flapping' within the flt/id collection in real-time.
drained allowing the liver to herniate through the diaphragmatic defect. The US appearances are summarized in Table 2.
DISCUSSION In the United Kingdom the commonest cause of diaphragmatic rupture is blunt trauma, most often sustained as a result of a road traffic accident, but OCcasionallyfollowing a fall or cave-in injury (Bekassy et al., 1972). Penetrating injury, from knife or gun shot, is an important cause in the USA (Hegarty et al., 1978; Estrera et al., 1979). Rarely so-called 'spontaneous' rupture OCcurs following sudden severe exertion (Bekassy et al., 1972). Several large surgical series have reviewed rupture of the diaphragm secondary to blunt trauma and report an OVerwhelming predominance of left sided injury, varying from 94-98% (Hedblom, 1934; Bernatz et al., 1958; Wall, h1963; E bert et al., 1967). However , more recent series ave reported the proportion of right sided rupture as 22 46% (Christiansen et al., 1974; McCune et al., 1976; l~Strera et al., 1979; Waldschmidt and Laws, 1980; Aronoffet al., 1982; Ball et al., 1982), and a post-mortem
Fig. 5 - Oblique longitudinal ultrasound scan of patient C. The liver is shown herniating through a large defect in the diaphragm. The intact anterior and posterior~aspects of the diaphragm are arrowed (D--+). There is no evidence of subphrenic fluid but a sub-pulmonary fluid collection above the 'bare' liver is demonstrated (F).
study showed an overall incidence of diaphragmatic hernia, in deaths from multiple trauma, of 5.2% with an equal left to right ratio (Estrera et al., 1979). Moreover, the degree of associated injury was not different between the two groups. The implication from these studies is that right-sided diaphragmatic rupture is more common than
100
CLINICALRADIOLOGY
once thought and perhaps is as likely to occur as left-sided rupture. This conflicts with the often quoted protective effect that the liver confers on the right diaphragm and is supported by Bekassy et al. (1972) who carried out experimental ruptures of diaphragms from cadavers and showed no statistical difference in the pressures required to rupture the right compared with the left hemidiaphragm. It is probable that the diagnosis is missed, partly because of a lack of awareness, but also because of the lack of definitive investigation to confirm the diagnosis. The methods whereby the diagnosis of left-sided rupture can be made are well described. They include the use of plain radiographs, barium studies of the upper and lower gastro-intestinal tract, CT and ultrasound (Fataar and Schutman, 1979; Heiberg et al., 1980; Ammann et al., 1983; Aronoffet al., 1982; Perlman et al., 1984; Aronchick et al., 1988). It has been suggested that a suspected diagnosis of right-sided rupture can be confirmed by inducing a pneumoperitoneum and demonstrating a pneumothorax or delineating the hernia without inducing a prieumothorax (Clay and Hanlon, 1951; Peck, 1957; Christiansen et al., 1974). This procedure is not diagnostic in all cases, since neither of the above features may be seen, and it is potentially dangerous to induce a pneumothorax in patients who are seriously injured (Estrera et aL, 1979; Aronoff et al., 1982). Liver scintigraphy will demonstrate liver herniation with a characteristic constriction band (Ball et al., 1982): the investigation is not easily performed in acutely ill patients and will not be useful unless there is liver herniation. Coeliac axis angiography has also been advocated but has similar limitations (Estrera et al., 1979). Barium studies only demonstrate herniation of colon in a very small number of patients (Strode and Vance, 1953; Peck, 1957). It is interesting to note the similarity of the chest radiographic appearances in all four of our patients: there was little evidence of chest trauma in the form of rib fracture, pneumothorax, significant lung contusion or mediastinal widening. Yet in all cases there was evidence of a haemothorax which was either free flowing or subpulmonary in position, the erect chest radiograph demonstrating an apparent raised right hemidiaphragm with a lateral peak. Despite the fact that the right hemidiaphragm cannot be identified as a separate structure, the above radiographic features should raise the suspicion of diaphragmatic rupture in a patient who has sustained blunt trauma. CT can be helpful in establishing the diagnosis of rupture of the left hemidiaphragm (Heiberg el al., 1980), but it has been reported as unhelpful in the diagnosis of right sided rupture (Nilsson et al., 1988). CT may show an elevated liver but cannot demonstrate the defect in the diaphragm, although the observation that the liver appears in an unusual position in the hemithorax offers indirect evidence of diaphragmatic rupture (Fig. 2). There have been three other reports on the use of US in the diagnosis of diaphragmatic rupture (Rao and Woodlief, 1980; Ammann et al., 1983; Nilsson et al., 1988). Two of these cases concerned the right hemidiaphragm and in only one was the diagnosis made acutely. Our small series demonstrates the utility of ultrasound as an accurate method for assessing right-sided diaphragmatic injuries. It can be performed easily and rapidly, if necessary using portable apparatus. The diaphragm is imaged directly from above via the pleural fluid 'window', and from
below through the liver, enabling accurate assessment of its continuity. The ultrasound appearances fit into two broad categor. ies which are diagnostic. Firstly, fluid is demonstrated above and below the diaphragm and the discontinuous free edge of the diaphragm can be seen as a 'flap' within the fluid (Figs 3 and 4). Secondly, the 'bare' surface of the liver is seen herniating through t'he defect in the dia. phragm which it tends to plug (Fig. 5). This secondary phenomenon is more likely to be seen following drainage of the haemothorax. The importance of making the diagnosis of rupture of the diaphragm has been emphasized with respect to the left leaf (Hegarty et al., 1978; Ball et al., 1982). Delay in diagnosis results in significant morbidity and mortality due principally to strangulation of bowel herniating through the defect (Carter et al., 1951; Hegarty et al., 1978). However, there is little evidence that right sided rupture is associated with significant morbidity or mor. tality. Following rupture liver herniates through the diaphragm to a variable degree, depending on the size of_ the defect, effectively plugging it. Bowel herniation is much less common than on the left and a delayed diagnosis is often made incidentally during investigation for non-specific or unrelated symptoms or at surgery or post-mortem (Peck, 1957; Ball et al., 1982). The importance of establishing the diagnosis of rightsided rupture early lies in the potential for management errors to occur if chest drains are placed in ignorance of the elevated position of the liver. Knowledge of this injury is also important in the long term, particularly with herniation of the liver, since it will prevent erroneous clinical and radiographic diagnoses at a later date (Peck et al., 1957; Ball et al., 1982). We believe that ultrasound is the definitive investigation for the diagnosis of rupture of the right hemidiaphragm. A high index of suspicion must be maintained in the clinical context of blunt trauma when interpreting the chest radiograph and CT so that ultrasound is performed promptly. Acknowledgement:We thank Mrs Lyn Dean for her help in preparing this manuscript. REFERENCES Ammann, AM, Brewer, WH, Maull, KI & Walsh JW (1983). Traumati~ rupture of the diaphragm: real-time sonographic diagnosis. Ameri" can Journal of Roentgenology, 140, 195-196. Aronchick, JM, Epstein, DM, Grefter, WB & Miller, WT (1988), Chronic traumatic diaphragmatic hernia: the significance of pleural effusion. Radiology, 168, 675-678. Aronoff, RJ, Reynolds, J & Thal, ER (1982). Evaluation of diaphrag" matic injuries. The American Journal of Surgery, 144, 671-674. Ball, T, McCory, R, Smith JO & Clements, JL (1982). Traumatic diaphragmatic hernia: errors in diagnosis. American Journal of Roentgenology, 138, 633-637. Bekassy, SM, Dave, KS, Wooler, GH & Ionescu, MI (1972). 'Sponta" ne0us' and traumatic rupture of the diaphragm. Annals of Surgery, 177, 320 323. Bernatz, PE, Burnside, AF & Clagett, OT (1958). Problems of the ruptured diaphragm. Journal of the American Medical Associatiots, 168, 877-881. Carter, BN, Giuseffi, J & Felson, B (1951). Traumatic diaphragmatic hernia. Amer&an Journal of Roentgenology, 65, 56-71. Christiansen, LA, Stage, P, Bille Braffe, E & Bertelsen, S (1974)' Rupture of the diaphragm. Thorax, 29, 559-563. Clay, RC & Hanlon, CR (1951). Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. Journal of Thoracic Surgery, ~1, 57-69.
RUPTURE OF THE RIGHT HEMIDIAPHRAGM FOLLOWING BLUNT TRAUMA Ehert PA, Gaertner, RA & Zuidema, GD (1967). Traumatic diaphragm'atic hernia. Surgery, Gynaecology and Obstetrics, 125, 59-65. Estrera, AS, Platt, MR & Mills, LJ (1979). Traumatic injuries of the diaphragm. Chest, 75, 306-313. Fataar S & Schulman, A (1979). Diagnosis of diaphragmatic tears. British Journal of Radiology, 52, 379-381. Hedblom, CA (1934). Diaphragmatic hernia. Annals of Internal Medicine, 8, 156-176. Hegarty, MM, Bryer, JV, Angorn, IB & Baker, LW (1978). Delayed presentation of traumatic diaphragmatic hernia. Annals of Surgery, 188, 229-233. Heiberg, E, Wolverson, MK, Hurd, RN, Jagannadharao, B & Sundaram, M (1980). CT recognition of traumatic rupture of the diaphragm. American Journal of Roentgenology, 135, 369 372. Lucido, JL & Wall, CA (1963). Rupture of the diaphragm due to blunt trauma. Archives of Surgery, 86, 989-999. McCtme, RP, Roda, CP & Eckert, C (I 976). Rupture of the diaphragm caused by blunt trauma. The Journal of Trauma, 16, 531-537.
101
Nilsson, PE, Aspelin, P, Ekberg, O & Senyk, J (1988). Radiologic diagnosis in traumatic rupture of the diaphragm. Acta Radiologica, 29, 653-655. Peck, WA (1957). Right-sided diaphragmatic liver hernia following trauma. American Journal of Roentgenology, 78, 99-108. Perlman, SJ, Rogers, LF, Mintzer, RA & Mueller, CF (1984). Abnormal course of nasogastric tube in traumatic rupture of left hemidiaphragm. American Journal of Roentgenology, 142, 85-88. Rao, KG & Woodlief, RM (1980). Grey scale ultrasonic demonstration of ruptured right hemidiaphragm. British Journal of Radiology, 53, 812-814. Strode, EC & Vance, CA (1953). Herniation of the right diaphragm secondary to trauma. Annals of Surgery, 137, 609-613. Waldschmidt, JL & Laws, HL (1980). Injuries of the diaphragm. The Journal of Surgery, 20, 587-591.
Rupture of the Right Hemidiaphragm Following Blunt Trauma: The Use of Ultrasound in Diagnosis J. M. sOMERS, F. V. GLEESON and C. D. R. F L O W E R Department of Diagnostic Radiology, Addenbrooke's Hospital, Cambridge Diaphragmatic rupture occurs in approximately 5% of patients who sustain multiple trauma and post-mortem studies suggest that right-sided rupture is more common than generally realized. Four cases of rupture of the right hemidiaphragm secondary to blunt trauma are presented. The chest radiographs were all similar, demonstrating a right sided fluid collection and right lower lobe consolidation in all patients. No patient had a pneumothorax. CT was useful only in retrospect, demonstrating a posterior eventration of the liver into the thorax in two patients. Ultrasound proved diagnostic in all cases demonstrating either the free edge of the diaphragm as a flap within the pleural fluid or the liver herniating into the thorax. The value of ultrasound as a simple, non-invasive and direct means of imaging the diaphragm is emphasized. Somers, J.M., Gleeson, F.V. & Flower, C.D.R. (1990). Clinical Radiology 42, 97-101. Rupture of the Right Hemidiaphragm Following Blunt Trauma: The Use of Ultrasound in Diagnosis
Rupture of the diaphragm occurs in approximately 5 % of patients sustaining multiple injuries, and the diagnosis is often delayed with serious consequences (Bekassy et al., 1972; Hegarty et al., 1978; Estrera et al., 1979). The radiographic criteria for the diagnosis of rupture of the left hemidiaphragm, both at the time of injury and when ddayed, have been well described (Hegarty et al., 1978; Heiberg et al., 1980; Aronoff et al., 1982; Ball et al., 1982; Ammann et al., 1983; Perlman et al., 1984; Aronchick et al., 1988). Post-mortem studies, demonstrating an equal distribution of left and right-sided diaphragmatic rupture, suggest that rupture of the right hemidiaphragm is probably underdiagnosed (Estrera et al., 1979). We present our experience of four patients seen over a period of 3 years following road traffic accidents, in whom the diagnosis of rupture of the right hemidiaphragm was made within 24 hours of injury using ultrasound (US). The value of the chest radiograph and computed tomography (CT) is discussed. PATIENTS AND M E T H O D S Between June 1986 and May 1989 four adult male patients (aged 18-47 years) were admitted to Addenbrooke's or Papworth hospitals following blunt right sided chest and abdominal trauma sustained in road traffic accidents. Table 1 outlines the clinical presentation, injuries sustained, early investigations performed and clinical OUtcome. All four patients had frontal chest radiographs (one supine and three erect), on admission to hospital. Patients A, C and D underwent computed tomography of the chest and abdomen to evaluate the extent of injury to major vessels and viscera. Eight millimetre thick slices Wereobtained at 1.5 cm intervals, before and after bolus Correspondenceto: Dr C. D. R. Flower,Department of Diagnostic R~ology, Addenbrooke's Hospital, Hills Road, Cambridge CB2
intravenous contrast enhancement, through the mediastinum and or upper abdomen, using a Siemen's Somaton II machine. All four patients had US examinations of the chest and upper abdomen either before or immediately "after CT. Patients A and B were examined using a Siemens Sonoline SX with a 3.5 MHz sector transducer. Patients C and D were examined using an Eloka Echo camera SSD 650, using a 3.5 MHz linear array transducer. RESULTS Chest Radiograph
Three patients (A, B and D) had erect frontal radiographs on admission; because of the severity of his injuries a supine chest radiograph was performed on patient C. All showed similar features: 1 No rib fractures were evident on the chest radiograph, although fractures of the lower ribs were seen subsequently on a control film performed as part of an intravenous urogram (Patient A) and at CT (Patient C) 2 All patients had haemothoraces confirmed by ultrasound and drained by pleural intubation. In two patients the fluid was subpulmonary simulating a high right hemidiaphragm (Fig. 1). 3 All patients had right basal pulmonary consolidation. Computed Tomography
The diagnosis of rupture of the right hemidiaphragm was not made on the basis of the CT appearances at the time of the examination in any patient. However, on review, features suggesting this diagnosis were noted in patients A and C. In normal subjects, when scanning at the level o f the diaphragm, the liver appears in the anterior half of the right hemithorax on the most cephalad scan, and then extends posteriorly on more caudal scums. The appearance in two of our patients was quite different (Fig. 2): the diaphragm first appears in the posterior half of the hemithorax and extends anteriorly
98
CLINICAL RADIOLOGY
Table 1 - Summary of clinical presentation, management and outcome
Patient
Age
Sex
Nature of trauma
Associated injuries
Management
Outcome
A
26
M
Driver-impact from driver's side
Right haemothorax Fractures to right 10th and 1 lth ribs Right lung contusion Soft tissue contusion
Conservative
Well on discharge at 12 days
B
18
M
Driver-impact from driver's side
Right haemothorax Liver laceration
Surgical repair of liver and diaphragm
Well on discharge at 11 days
C
32
M
Driver-changing tyre on hard shoulder of motorway. Hit from right side.
Bilateral haemothoraces Crush fractures T4, T5, T6 Multiple rib fractures Lacerated liver and spleen Segmental infarct right kidney
Splenectomy Repair of liver Right hemidiaphragm not repaired
Moderate hypertension on discharge at 6 weeks
D
47
M
Driver-impact driver's side
Right haemothorax Tear in small bowel mesentery
Repair of mesentery Repair of diaphragm Dialysis for acute tubular necrosis
Well with normal renal function on discharge
Fig. 1 - Chest radiograph in patient A showing an apparent elevation of the right hemidiaphragm with a lateral peak, suggesting sub-pulmonary fluid. Note the lack of obvious trauma to the rib cage, lung or mediastinum - a feature noted in all four patients.
(a)
on subsequent caudal scans. In the third patient the CT appearance was similar to the normal situation except that the liver was elevated into the chest. The appearance of the diaphragmatic crura was normal in all three cases, and the diaphragm itself could not be distinguished as a separate structure. Ul~asound
In all four patients the diagnosis of rupture of the right hemidiaphragm was made with confidence on the basis of the ultrasound findings. In all patients the defect resulting from the diaphragmatic tear was clearly visible and in two patients the torn free edge could be seen flapping within a fluid collection which extended from the 'bare' surface of the liver to the pleural space beneath the lung (Figs 3 and 4). In two patients the free edge of the torn diaphragm was not identified but liver could be seen herniating through the diaphragmatic defect (Fig. 5). In one of these cases (patient C) the ultrasound diagnosis of rupture was made shortlY after a large haemothorax had been partially
(b) Fig. 2 - Consecutive CT slices in patient C. The liver (L) is in an elevated position and first appears in the posterior aspect of the hemithorax (a) and extends anteriorly on subsequent slices (b). Similar appearances were demonstrated in patient A.
RUPTURE OF THE RIGHT HEMIDIAPHRAGM FOLLOWING BLUNT TRAUMA
99
Table 2 - The U S appearances of rupture of the fight hemidiaphragm
patient
Liver
Freefluid
Diaphragm
A
Displaced upwards into the axilla
Subpulmonary and subdiaphragmatic
'Flapping' free edge of the diaphragm with a visible defect over the dome (Fig. 3)
B
Displaced upwards into the axilla ,m
Subpulmonary and subdiaphragmatic
'Flapping' free edge of the diaphragm with a visible defect over the dome (Fig. 4)
C
Displaced upwards with herniation through the diaphragmatic defect
Subpulmonary only
Defect over posterior aspect of the dome with herniation of 'bare' liver (Fig. 5)
D
Displaced upwards into the axilla
Subpulmonary and over 'bare' area of liver posteriorly
Only a small portion of the anterior aspect of the diaphragm visible with an extensive 'bare' area of liver posteriorly
Fig. 4 - Oblique ultrasound scan of patient B. Similar appearance to that in Fig. 3 with the free torn edge of the diaphragm ( D ~ ) clearly seen.
Fig. 3 - Longitudinal ultrasound scan of patient A. The diaphragm anteriorly and posteriorly is demonstrated (D~). Note the anterior aspect is free and could be seen 'flapping' within the flt/id collection in real-time.
drained allowing the liver to herniate through the diaphragmatic defect. The US appearances are summarized in Table 2.
DISCUSSION In the United Kingdom the commonest cause of diaphragmatic rupture is blunt trauma, most often sustained as a result of a road traffic accident, but OCcasionallyfollowing a fall or cave-in injury (Bekassy et al., 1972). Penetrating injury, from knife or gun shot, is an important cause in the USA (Hegarty et al., 1978; Estrera et al., 1979). Rarely so-called 'spontaneous' rupture OCcurs following sudden severe exertion (Bekassy et al., 1972). Several large surgical series have reviewed rupture of the diaphragm secondary to blunt trauma and report an OVerwhelming predominance of left sided injury, varying from 94-98% (Hedblom, 1934; Bernatz et al., 1958; Wall, h1963; E bert et al., 1967). However , more recent series ave reported the proportion of right sided rupture as 22 46% (Christiansen et al., 1974; McCune et al., 1976; l~Strera et al., 1979; Waldschmidt and Laws, 1980; Aronoffet al., 1982; Ball et al., 1982), and a post-mortem
Fig. 5 - Oblique longitudinal ultrasound scan of patient C. The liver is shown herniating through a large defect in the diaphragm. The intact anterior and posterior~aspects of the diaphragm are arrowed (D--+). There is no evidence of subphrenic fluid but a sub-pulmonary fluid collection above the 'bare' liver is demonstrated (F).
study showed an overall incidence of diaphragmatic hernia, in deaths from multiple trauma, of 5.2% with an equal left to right ratio (Estrera et al., 1979). Moreover, the degree of associated injury was not different between the two groups. The implication from these studies is that right-sided diaphragmatic rupture is more common than
100
CLINICALRADIOLOGY
once thought and perhaps is as likely to occur as left-sided rupture. This conflicts with the often quoted protective effect that the liver confers on the right diaphragm and is supported by Bekassy et al. (1972) who carried out experimental ruptures of diaphragms from cadavers and showed no statistical difference in the pressures required to rupture the right compared with the left hemidiaphragm. It is probable that the diagnosis is missed, partly because of a lack of awareness, but also because of the lack of definitive investigation to confirm the diagnosis. The methods whereby the diagnosis of left-sided rupture can be made are well described. They include the use of plain radiographs, barium studies of the upper and lower gastro-intestinal tract, CT and ultrasound (Fataar and Schutman, 1979; Heiberg et al., 1980; Ammann et al., 1983; Aronoffet al., 1982; Perlman et al., 1984; Aronchick et al., 1988). It has been suggested that a suspected diagnosis of right-sided rupture can be confirmed by inducing a pneumoperitoneum and demonstrating a pneumothorax or delineating the hernia without inducing a prieumothorax (Clay and Hanlon, 1951; Peck, 1957; Christiansen et al., 1974). This procedure is not diagnostic in all cases, since neither of the above features may be seen, and it is potentially dangerous to induce a pneumothorax in patients who are seriously injured (Estrera et aL, 1979; Aronoff et al., 1982). Liver scintigraphy will demonstrate liver herniation with a characteristic constriction band (Ball et al., 1982): the investigation is not easily performed in acutely ill patients and will not be useful unless there is liver herniation. Coeliac axis angiography has also been advocated but has similar limitations (Estrera et al., 1979). Barium studies only demonstrate herniation of colon in a very small number of patients (Strode and Vance, 1953; Peck, 1957). It is interesting to note the similarity of the chest radiographic appearances in all four of our patients: there was little evidence of chest trauma in the form of rib fracture, pneumothorax, significant lung contusion or mediastinal widening. Yet in all cases there was evidence of a haemothorax which was either free flowing or subpulmonary in position, the erect chest radiograph demonstrating an apparent raised right hemidiaphragm with a lateral peak. Despite the fact that the right hemidiaphragm cannot be identified as a separate structure, the above radiographic features should raise the suspicion of diaphragmatic rupture in a patient who has sustained blunt trauma. CT can be helpful in establishing the diagnosis of rupture of the left hemidiaphragm (Heiberg el al., 1980), but it has been reported as unhelpful in the diagnosis of right sided rupture (Nilsson et al., 1988). CT may show an elevated liver but cannot demonstrate the defect in the diaphragm, although the observation that the liver appears in an unusual position in the hemithorax offers indirect evidence of diaphragmatic rupture (Fig. 2). There have been three other reports on the use of US in the diagnosis of diaphragmatic rupture (Rao and Woodlief, 1980; Ammann et al., 1983; Nilsson et al., 1988). Two of these cases concerned the right hemidiaphragm and in only one was the diagnosis made acutely. Our small series demonstrates the utility of ultrasound as an accurate method for assessing right-sided diaphragmatic injuries. It can be performed easily and rapidly, if necessary using portable apparatus. The diaphragm is imaged directly from above via the pleural fluid 'window', and from
below through the liver, enabling accurate assessment of its continuity. The ultrasound appearances fit into two broad categor. ies which are diagnostic. Firstly, fluid is demonstrated above and below the diaphragm and the discontinuous free edge of the diaphragm can be seen as a 'flap' within the fluid (Figs 3 and 4). Secondly, the 'bare' surface of the liver is seen herniating through t'he defect in the dia. phragm which it tends to plug (Fig. 5). This secondary phenomenon is more likely to be seen following drainage of the haemothorax. The importance of making the diagnosis of rupture of the diaphragm has been emphasized with respect to the left leaf (Hegarty et al., 1978; Ball et al., 1982). Delay in diagnosis results in significant morbidity and mortality due principally to strangulation of bowel herniating through the defect (Carter et al., 1951; Hegarty et al., 1978). However, there is little evidence that right sided rupture is associated with significant morbidity or mor. tality. Following rupture liver herniates through the diaphragm to a variable degree, depending on the size of_ the defect, effectively plugging it. Bowel herniation is much less common than on the left and a delayed diagnosis is often made incidentally during investigation for non-specific or unrelated symptoms or at surgery or post-mortem (Peck, 1957; Ball et al., 1982). The importance of establishing the diagnosis of rightsided rupture early lies in the potential for management errors to occur if chest drains are placed in ignorance of the elevated position of the liver. Knowledge of this injury is also important in the long term, particularly with herniation of the liver, since it will prevent erroneous clinical and radiographic diagnoses at a later date (Peck et al., 1957; Ball et al., 1982). We believe that ultrasound is the definitive investigation for the diagnosis of rupture of the right hemidiaphragm. A high index of suspicion must be maintained in the clinical context of blunt trauma when interpreting the chest radiograph and CT so that ultrasound is performed promptly. Acknowledgement:We thank Mrs Lyn Dean for her help in preparing this manuscript. REFERENCES Ammann, AM, Brewer, WH, Maull, KI & Walsh JW (1983). Traumati~ rupture of the diaphragm: real-time sonographic diagnosis. Ameri" can Journal of Roentgenology, 140, 195-196. Aronchick, JM, Epstein, DM, Grefter, WB & Miller, WT (1988), Chronic traumatic diaphragmatic hernia: the significance of pleural effusion. Radiology, 168, 675-678. Aronoff, RJ, Reynolds, J & Thal, ER (1982). Evaluation of diaphrag" matic injuries. The American Journal of Surgery, 144, 671-674. Ball, T, McCory, R, Smith JO & Clements, JL (1982). Traumatic diaphragmatic hernia: errors in diagnosis. American Journal of Roentgenology, 138, 633-637. Bekassy, SM, Dave, KS, Wooler, GH & Ionescu, MI (1972). 'Sponta" ne0us' and traumatic rupture of the diaphragm. Annals of Surgery, 177, 320 323. Bernatz, PE, Burnside, AF & Clagett, OT (1958). Problems of the ruptured diaphragm. Journal of the American Medical Associatiots, 168, 877-881. Carter, BN, Giuseffi, J & Felson, B (1951). Traumatic diaphragmatic hernia. Amer&an Journal of Roentgenology, 65, 56-71. Christiansen, LA, Stage, P, Bille Braffe, E & Bertelsen, S (1974)' Rupture of the diaphragm. Thorax, 29, 559-563. Clay, RC & Hanlon, CR (1951). Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. Journal of Thoracic Surgery, ~1, 57-69.
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Nilsson, PE, Aspelin, P, Ekberg, O & Senyk, J (1988). Radiologic diagnosis in traumatic rupture of the diaphragm. Acta Radiologica, 29, 653-655. Peck, WA (1957). Right-sided diaphragmatic liver hernia following trauma. American Journal of Roentgenology, 78, 99-108. Perlman, SJ, Rogers, LF, Mintzer, RA & Mueller, CF (1984). Abnormal course of nasogastric tube in traumatic rupture of left hemidiaphragm. American Journal of Roentgenology, 142, 85-88. Rao, KG & Woodlief, RM (1980). Grey scale ultrasonic demonstration of ruptured right hemidiaphragm. British Journal of Radiology, 53, 812-814. Strode, EC & Vance, CA (1953). Herniation of the right diaphragm secondary to trauma. Annals of Surgery, 137, 609-613. Waldschmidt, JL & Laws, HL (1980). Injuries of the diaphragm. The Journal of Surgery, 20, 587-591.
