Diagnosis of diaphragmatic tears

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Abstract
Cases (25) of torn diaphragm with herniation of abdominal contents and 22 cases without herniation were studied. Without herniation, the chest radiograph was in most cases almost normal, the remainder showing hemothorax or pneumothorax attributable to associated lung or rib injury. With herniation, the chest radiograph was infrequently normal and a substantial number showed basal abnormality directly due to herniated viscera. The appearances were non-specific and led to a number of preliminary misdiagnoses and diagnostic delays. The herniated bowel can flatten out beneath the lung base to resemble a mildly elevated hemidiaphragm (the pseudo-diaphragm effect). Torn hemidiaphragm is a frequently forgotten diagnosis, but is of great importance because of hernial bleeding or strangulation. The peritoneopleural pressure gradient eventually produces herniation and is usually diagnosable by Ba study of stomach and colon. Small bowel studies are probably unnecessary. The limbs of the herniated loop are pinched together as they pass through the tear, sometimes severely enough to obstruct the Ba. Insufflated air may get through into an apparently obstructed hernia. Because it is a blind alley, the herniated gastric fundus will not produce these typical appearances and will be missed unless the amputated fundus sign is observed. Immediately following injury, normal Ba studies do not necessarily indicate that there is no tear because there may not be time for herniation to occur. The only available sign may be the presence of a pneumoperitoneum or of intra-abdominal visceral injury following a downward stab to the lower chest, or of pneumothorax following abdominal injury. Diagnostic pneumoperitoneum may have a place. A left-sided predominance in all series is due to the liver cushioning the right hemidiaphragm from rupture in abdomino-pelvic crush injuries and preventing bowel from herniating through established stab wounds.

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