Diaphragmatic Injuries: Why Do We Struggle to Detect Them?

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Diaphragmatic Injuries Why Do We Struggle to
Detect Them?
Michael N. Patlas, MD, FRCPC
Associate Professor of Radiology
Director, Division of Emergency/Trauma
Radiology McMaster
University, Hamilton, Canada
patlas_at_hhsc.ca
May 28 30, 2015, Montréal, Québec
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Disclosure Statement No Conflict of Interest
I do not have an affiliation, financial or
otherwise, with a pharmaceutical company, medical
device or communications organization. I have no
conflicts of interest to disclose ( i.e. no
industry funding received or other commercial
relationships). I have no financial relationship
or advisory role with pharmaceutical or
device-making companies, or CME provider. I will
not discuss or describe in my presentation at the
meeting the investigational or unlabeled
("off-label") use of a medical device, product,
or pharmaceutical that is classified by Health
Canada as investigational for the intended use.
May 28 30, 2015, Montréal, Québec
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Diaphragmatic Injuries Why Do We Struggle to
Detect Them?

• Michael N. Patlas, MD, FRCPC
• Associate Professor of Radiology
• Director, Division of Emergency/Trauma Radiology
• McMaster University, Hamilton, Canada
• patlas_at_hhsc.ca

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Disclosure Statement

• I, Dr. Michael Patlas, have no affiliations,
  sponsorships, honoraria, monetary support or
  conflict of interest from any commercial source

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Diaphragmatic Injury is
an
Old Diagnostic
Conundrum
1591-Daniel Sennertus described autopsy findings
of a gastric herniation due to traumatic
diaphragmatic injury
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Presentation
5 months later
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Introduction

• The diaphragmatic injury (DI) is an uncommon
  traumatic condition
• 0.8 - 8 of patients with blunt abdominal trauma
• Blunt DI (BDI) is undiagnosed at initial
  presentation in 7 - 66
• Desir A. RadioGraphics 2012

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Introduction

• Penetrating diaphragmatic injury (PDI) can be
  occult in 7 of cases
• Diaphragmatic injury does not resolve
  spontaneously can cause disastrous
  complications
• Dreizin D. Radiology 2013

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Learning Objectives

• To describe direct and indirect signs of blunt
  and penetrating diaphragmatic injury (DI)
• To highlight factors affecting detection of DI
• To discuss pitfalls in diagnosis of DI

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McMaster Experience

• January 1, 2008-December 21, 2012
• 3225 trauma patients
• 38 patients with DI (B and P)
• 24 cases with 64MDCT before laparotomy
• Correct preoperative diagnosis in 16/24 cases
• Leung V, Patlas M et al. CARJ 2015

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How Are We Doing in Real Life?

• 50 of BDIs had been diagnosed prospectively on
  admission helical CT retrospective review of the
  same cases showed sensitivity of 56 - 87 (Nchimi
  A. AJR 2005)
• 58 - prospective identification of DI on MDCT
• (BDI-77, PDI-47) correct retrospective
  injury side determination in 91 - 94 (Hammer
  MM. Emerg Radiol 2014)

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Why Do We Struggle?

• Trauma patients are poor historians
• Referring physicians are not always good
  historians
• Uncommon injury
• Lack of awareness by clinicians and radiologists
• There are no specific clinical signs of
  diaphragmatic injury

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Why Do We Struggle?

• Multitrauma patients with associated injuries
  in 52-100 of cases
• Right-sided defects are difficult for detection
  due to lack of contrast between diaphragm and
  liver
• Tiny defects in penetrating injury (PI)
• Rees O. Clin Radiol 2005

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Why Do We Struggle?

• There is no herniation of abdominal organs in
  many cases of PI
• We have to rely on indirect signs

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Which side-BDI?

• BDI occurs more often on the left side
  (L to R ratio
  of 31)
• Protective effect of liver on the right side
• Area of congenital embryological weakness
• in the posterolateral aspect of the left
• hemidiaphragm
• Greater inherent resistance of the right
• hemidiaphragm (Patlas M. Radiol Med 2015)

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Which side-BDI?

• Steering wheel on the left side of the car in
  most countries
• Underdiagnosis of right-sided BDI (subtle signs,
  high mortality due to associated injuries)
  
• Desir A. RadioGraphics 2012

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Which side-PDI?

• No predilection for side is seen with GSW
• The majority of stab wounds are on the left
• side (high percentage of right-handed
• attackers)
• Bodanapally UK. Eur Radiol 2009

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Site and Size

• BDI usually located at posterolateral area
• BDI-large tears (more than 10 cm)
• No predilection for site with GSW
• Small size of PDI (1-2 cm)

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Complications

• Spontaneous healing of DI has never been reported
• Negative pleuroperitoneal pressure gradient
• contributes to the persistence of the defect
• Abdominal structures herniate into thorax
• Leung V, Patlas M et al. CARJ 2015

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Complications

• Stomach, colon, spleen and omentum herniate in
  cases of left-sided DI
• Liver herniates in right-sided DI
• Life-threatening complications- incarceration and
  ischemia of herniated organs

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Teaching Point Combination of Different Direct
and Indirect Signs
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Stab wound with 1.5 cm diaphragmatic defect
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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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• What happens if we miss?

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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Imaging Signs on MDCT

• Direct signs
• Segmental diaphragmatic defect
• Dangling diaphragm
• Indirect signs
• Herniation through the defect
• Collar
• Hump and Band
• Dependent viscera
• Thickening of the diaphragm
• Contiguous injury
• Pneumothorax and pneumoperitoneum

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• Atraumatic
• defect
• Most often on
• the left side
• Elderly
• patients
• Small defects
• No
• additional
• signs of DI

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How can we help ourselves?

• Obtain as much clinical information as you can
• 42 of penetrating DI happen in patients with
  entry wounds in thoracoabdominal area defined by
  nipple line superiorly and costal margin
  inferiorly (Bodanapally UK et al. Eur Radiol
  2009)
• Use your best scanner to evaluate trauma patients
  (speed and resolution)

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How can we help ourselves?

• Remember anatomic variants
• Small gap in posterior diaphragm between
  crura
• and lateral arcuate ligaments is seen in
  11 of
• population, more often in elderly people
  
• Restrepo CS et al. RadioGraphics 2008

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How can we help ourselves?

• Check all phases for signs of DI (arterial and
  delayed phases for wound tract outlined by the
  blood, portal phase for the band sign)

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How can we help ourselves?

• MPRs (dangling diaphragm, hump and band signs,
  collar sign)
• Dont misinterpret band sign as linear hepatic
  laceration
• ALWAYS SUSPECT DIAPHRAGMATIC INJURY

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Conclusions

• We have to rely on indirect signs in many
• cases due to low sensitivity of direct signs
• Small rents in PDIs present a diagnostic
• challenge
• Think about trajectory
• Use MPRs to assess the diaphragm

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• Thank you!