Diaphragm Trauma - Symptoms and Management

Introduction

A delicate, thin muscle is attached to a bone called the sternum, which is in the middle of the chest wall, to the ribcage, and to a part of the spine. This muscle is dome-shaped. The diaphragm helps an individual breathe. The chest cavity is separated from the abdominal cavity by the diaphragm.

The rhythmic and involuntary movements of the diaphragm are important for various reasons in the human body. Trauma to the diaphragm interferes with the proper functioning of the muscle, subsequently affects the surrounding organs, and causes pain and discomfort.

What Are the Functions of a Diaphragm?

The diaphragm is a thin and delicate muscle, yet it plays critical roles through its contracting (downward movement) and relaxing (upward movement) movements, which can be categorized into respiratory and non-respiratory functions.

• Respiratory Functions:

  • Inhalation - When an individual takes a breath, the diaphragm muscle moves down (contracts), creating more space in the lungs. This creates a pressure difference between the pressure of the lung (lower pressure) and the air pressure outside the body (higher pressure), subsequently causing the air to flow into the lungs.

  • Exhalation - The diaphragm begins to relax post-contraction. This again causes a pressure difference in the lung (higher pressure) and outside the body (lower pressure), which subsequently causes air to be expelled out of the lungs, enabling one to breathe out.

• Non-Respiratory Functions:

  • Relaxation of the diaphragm tends to pressurize the abdomen, which urges one to urinate and defecate.

  • Movement of the diaphragm also adds pressure to the food pipe (esophagus) and prevents regurgitation (where digested food moves from the stomach back into the mouth).

  • Acts as a pump that compresses blood vessels and helps fill the heart.

  • The negative pressure created by the diaphragm during inhalation helps to maintain the forward flow of lymphatic fluid toward the bloodstream.

Several things can cause trauma to the diaphragm. The repair of which, if delayed, could be crucial.

What Are the Types of Diaphragm Trauma?

The diaphragm muscle can get injured by a variety of factors, such as a medical mishap during a surgical procedure in the area surrounding the diaphragm or an accident. The left side of the diaphragm is more commonly involved than the right side of the diaphragm. There are two main types of diaphragm trauma:

• Penetrating Trauma: When the chest or abdomen is penetrated with an object that is usually sharp and causes a tear or punctures the diaphragm muscle, this type of trauma occurs. Most of the time, gunshot wounds, stab wounds, or other penetrating injuries cause piercing trauma to the diaphragm. Penetrating diaphragm traumas are usually smaller than 3 cm in size.

• Blunt Trauma: When the diaphragm is subjected to a sudden force or impact, which can cause it to tear or rupture, it is referred to as blunt trauma. Blunt trauma to the diaphragm is usually caused by motor vehicle accidents, falls, or other high-impact injuries. Blunt diaphragm traumas are larger and may extend up to 15 cm in size.

Both penetrating and blunt trauma to the diaphragm can result in serious complications, such as herniation (where the organ protrudes into a space where it does not belong) of abdominal organs into the chest cavity, which can compress the lungs and cause respiratory distress.

What Are the Symptoms of Trauma to the Diaphragm?

Symptoms an individual may experience following trauma to the diaphragm may differ depending on the severity of the trauma and how early one presents for clinical assessment.Some of the signs and symptoms of diaphragm trauma are as follows:

• Signs of diminished breathing may be seen on the affected side.

• Sharp or dull pain in the chest.

• Pain in and around the abdomen.

• Dyspnea - a feeling of breathlessness.

• Coughing.

• Tachycardia - increased heart rate.

• Sounds of bowel movements on auscultation of the chest area.

• Nausea and vomiting due to obstructive bowel movements.

• Difficulty in swallowing food due to food regurgitation.

• Breathing shows chest expansion in an asymmetrical pattern.

• Abdominal distention due to herniation of abdominal organs through the tear of the diaphragm.

• Severe cases and delayed intervention may cause sepsis in some individuals.

How to Diagnose Diaphragm Trauma?

Since the symptoms of diaphragm trauma can mimic those of chest or abdominal disease conditions, diaphragm trauma may be difficult to diagnose at the earliest. A thorough history, physical examination, and diagnostic imaging tests help diagnose diaphragm trauma.

• History- The presentation of symptoms along with a history of an accident or a recent surgical procedure surrounding the diaphragm area helps suspect a case of diaphragm trauma.

• Physical Examination- Examination of the chest area indicating obstruction in the airway, breathing, circulation, disability, or exposure (ABCDEs) can help suspect diaphragm trauma. Bowel sounds and diaphragm dysfunction may also be present on auscultation of the chest wall. Physical examination alone is not a promising diagnostic tool.

• Imaging Studies- Imaging studies such as chest X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasound can be used to diagnose diaphragmatic injuries. CT scans and MRI are considered the most sensitive and specific imaging modalities for detecting diaphragm trauma, as chest X-rays may not reveal diaphragm trauma that is small.

How to Treat Diaphragm Trauma?

The diaphragm moves in a rhythmic pattern, regardless of the trauma. This constant movement prevents healing from trauma of any size and requires close monitoring and subsequent surgical intervention. Surgical repair aims at closing the tear and repositioning any organs that herniated through the diaphragm and into the chest cavity.If the injury site has been contaminated with intestinal contents, foreign materials, or damaged tissue, it is necessary to thoroughly clean the wound and remove any dead or unhealthy tissue.

If an approximation of the tear is not possible, healthy tissue from the individual or a surgical mesh may be used to repair the damaged diaphragm. Surgical methods for diaphragm trauma repair include:

• Laparotomy - The incision is placed along the abdominal wall to access the abdominal cavity.

• Thoracotomy - The incision is placed between the ribs to access the chest cavity.

• Combined Laparotomy and Thoracotomy - If the diaphragm tear is bilaterally involved, both approaches may be required.

• Laparoscopy - A surgical procedure that is minimally invasive and uses a camera that is attached to a sleek rod. This approach helps the body heal faster with minimal scarring.

Individuals who have undergone surgery to repair diaphragm trauma are usually discharged the next day or two days later. To aid in the recovery process, pain medication is given, and one is advised to avoid lifting heavy objects and physical activities for at least a month.

What Are the Risks of Diaphragm Trauma Repair?

Like any surgical procedure, repair of the diaphragm may also cause certain risks, such as:

• Bleeding or infection at the surgical site.

• Allergic reaction to anesthesia.

• Persistent breathing issues.

• Formation of blood clots.

• Damage to organs near the diaphragm.

Conclusion

Symptoms being similar to those of other conditions affecting organs such as the heart and lungs, it can be challenging to diagnose diaphragm injuries, making a high level of suspicion critical. The method of repairing the diaphragm depends on whether it is unilaterally or bilaterally affected. Possible complications include respiratory failure, infections, and bleeding, and the long-term prognosis relies on the health of the individual and the severity of the injury. However, in general, the prognosis is positive after a diaphragm repair procedure.