Traumatic diaphragmatic injury: a narrative review

Introduction

Traumatic diaphragmatic injury (TDI) is a relatively uncommon traumatic injury, with an incidence ranging from 1–15% in trauma, but can be associated with a high mortality rate of 30–45% (1-3). Given the relative rarity of the injury, general knowledge and related research are scarce. A recent 2020 review focused on presentation and radiologic diagnosis, but a comprehensive, up-to-date review that also provides explicit diagnostic and surgical recommendations is currently lacking. This review will provide up-to-date information for improved recognition and treatment of TDI. We present this article in accordance with the Narrative Review reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-13/rc).

Methods

This narrative review was performed utilizing PubMed to search English-language biomedical literature. The following search terms were utilized: “diaphragmatic hernia”, “diaphragm rupture”, “diaphragm injury”, “trauma”, “traumatic diaphragm hernia”. Literature review included manuscripts from 2000 to 2025. All study types involving adult patients were considered. The senior authors reviewed literature for inclusion (Table 1).

Epidemiology

The overall prevalence of TDI varies widely across the literature. Almost 8% of patients undergoing laparotomy or thoracotomy for other traumatic injuries were incidentally found to also have a TDI (1). Recent studies of TDI showed that the incidence differs between penetrating and blunt trauma etiologies, with an incidence of 1–7% in blunt trauma versus 10–15% in penetrating trauma (2,3). The increasing frequency of computed tomography (CT) imaging in trauma patients has been associated with an overall increase in incidence of these injuries over time (2), due to improvements in detection. Laterality of the diaphragmatic injury also differs based upon the type of trauma. Blunt trauma patients are more likely to have left-sided TDIs than right-sided injuries, which is due largely to a congenital weakness formed by the fusion of the costal and lumbar portions of the left hemidiaphragm. The liver also affords some protection to the right hemidiaphragm. A 2017 review reported 75% left-sided diaphragmatic hernias versus 25% right-sided in blunt trauma patients (2). Bilateral TDIs are rare, seen in 2% of all patients with TDI.

A higher mortality is seen with right-sided TDI when compared to the left, attributed to the greater force required to injure the right hemidiaphragm as the liver is usually protective (2,4). If an injury is seen on the right, there is likely associated liver and vascular injury that carries an increased risk of mortality. Mortality rates for TDI have been described as high as 30% for penetrating trauma and up to 45% for blunt trauma (3). The higher mortality with blunt mechanisms of injury may be associated with the larger disruption of the diaphragm and higher frequency of associated solid organ and hollow viscous injuries (4).

Anatomy and physiology of the diaphragm and thorax

The diaphragm is the domed musculotendinous structure serving as the floor of the thoracic cavity and the most superior aspect of the abdominal cavity (5). It includes muscular attachments peripherally to the xiphoid process of the sternum, costal cartilage of the seventh through tenth ribs, bony portion of ribs eleven and twelve, and the lumbar vertebra. Centrally, the muscle fibers integrate to form a central tendon, which ascends to fuse with the inferior portion of the fibrous pericardium. Posteriorly, the right crus arises from the L1–3 vertebral bodies and their discs, and the left crus arises from L1–2. The crus ascend to encircle the outlet of the esophagus in a sling-like loop at the level of T10. The medial margins additionally converge to form a tendinous arc anterior to the aorta called the median arcuate ligament (6).

The diaphragm is the primary muscle of respiration. With contraction, it moves inferiorly, increasing the volume of the thoracic cavity. This reduces intrathoracic pressure, allowing the lungs to expand. At rest in the supine position, there is a positive gradient of 7–20 cmH₂O between the intraperitoneal and intrapleural pressure. With maximum respiratory effort, this positive pressure increases to 100 cmH₂O. During severe blunt abdominal trauma, intra-abdominal pressure can suddenly increase to 200 cmH₂O, transferring significant kinetic energy to the diaphragm and leading to disruption (7). This laceration or defect of the diaphragm results in the loss of the physiologic pressure gradient between the pleural cavity and peritoneal cavity, allowing for migration of intraabdominal organs into the thoracic cavity. It can also cause impairment of respiratory and circulatory mechanics. With the continuous movement of the diaphragm and constant pressure differential, defects in the diaphragm generally do not spontaneously heal. Moreover, these defects have been shown to increase in size over time, with greater risk of morbidity and mortality (8).

Clinical presentation

Patients with TDI can vary extensively in presentation, based upon the size and location of the injury, abdominal visceral organ displacement, and other distracting injuries (9). Maintaining a high index of suspicion is crucial when caring for patients who experience mechanisms of injury with the energy to produce a diaphragmatic injury. These can include thoracoabdominal penetrating injuries, high-speed motor vehicle accidents, multi-story falls, direct blows to the abdomen, and abdominal crush injuries. In penetrating injury, the injury causes a direct laceration to the muscle fibers, with smaller defects that are difficult to detect. However, in blunt trauma, a direct impact to the abdomen causes a transmission of force through the abdominal viscera, which increases intraabdominal pressure and leads directly to disruption. This obviously has a high association of intraabdominal solid organ injury, hollow viscus injury, and vascular tears, particularly in the inferior vena cava or hepatic veins (1,9).

The acute phase of diaphragm injury is considered the time from traumatic insult until recovery from the primary injury. The clinical presentation of acute diaphragmatic injury is widely variable, as it can be dependent on coexisting injuries. The classic symptoms include epigastric or referred shoulder pain and cardio-respiratory compromise (7). Patients may also be completely asymptomatic, especially with smaller injuries or lack of associated organ herniation. Finally, patient’s with severe distracting injuries (such as traumatic brain injury, traumatic amputation, or extensive chest wall trauma) may also not portray symptoms specifically related to the TDI.

Up to 30% of diaphragmatic injuries are detected in a delayed fashion, ranging from weeks to months after the initial insult (10). In addition to epigastric and chest pain, delayed presentation has a higher incidence of symptoms associated with herniation of abdominal contents. These include the classic signs of obstruction, such as nausea, vomiting, and obstipation. On exam, it may be possible to auscultate intrathoracic bowel sounds, and if allowed to progress, the patient can develop signs of peritonitis secondary to organ ischemia (11). The patient may demonstrate diminished chest wall expansion, decreased resonance, and cardiac displacement leading to respiratory compromise and circulatory collapse (9).

Diagnosis

Diagnosis of TDI remains difficult, in large part due to the broad spectrum of severity and variable clinical presentation. Trauma patients with obvious operative indications, such as hemodynamic instability or peritonitis, will have a traumatic diaphragmatic hernia diagnosed via direct visualization intraoperatively. However, a high index of suspicion in the hemodynamically stable trauma patient remains critical to reduce the incidence of missed TDI. Multiple diagnostic modalities exist, both non-invasive and procedural. Table 2 highlights these various diagnostic tools, along with a brief discussion of their advantages and limitations.

The most frequent first-line diagnostic modality is the chest radiograph (CXR), usually obtained for trauma patients. Unfortunately, CXRs are frequently normal despite the presence of a TDI (2,4) and should not be employed as the only diagnostic modality when there is high suspicion for injury. Findings that can be diagnostic on initial CXR include the presence of hollow viscera (stomach, small intestine, or colon) in the chest, a nasogastric tube coiling in the thoracic cavity, or a severely elevated hemidiaphragm on the side of trauma. Most commonly, nonspecific findings such as a small pneumothorax are the only abnormality present (2). CXR also cannot detect TDI that are small enough to preclude herniation of intra-abdominal contents. The sensitivity of CXR for left-sided diaphragmatic injury is 27–68%, while the sensitivity for right-sided diaphragmatic injury is only 17–33% (12).

Ultrasound has been described as revealing a TDI with herniated abdominal contents when performed by an experienced sonographer. In one study of penetrating trauma patients, ultrasound had a sensitivity of 50% and a specificity of 100% for TDI (13). However, looking for TDI is not a routine part of the focused abdominal sonography for trauma (FAST) and has not been described robustly in the literature (2).

CT scans are now frequently obtained for trauma patients and have an improved ability to detect TDI when compared to CXR. In fact, a CT scan of the chest and abdomen with multiplanar reconstruction is considered the gold standard for non-invasive diagnosis of traumatic diaphragmatic hernias (14). The sensitivity of a CT scan in detecting TDI varies in the literature, ranging from 56% to 83% (1,4). The specificity is slightly better, from 78% to 100% (14). CT scans are more sensitive for diagnosing left-sided TDIs. This is secondary to the lack of intervening fat between the liver and the right hemidiaphragm, as well as similar contrast enhancement of these two structures (12). When comparing TDI resulting from blunt versus penetrating mechanisms of injury, sensitivity and specificity of CT scans also differ. A 2023 meta-analysis showed a sensitivity of 74% and specificity of 92% for the diagnosis of penetrating TDI utilizing CT, though significant heterogeneity among the studies was noted (15). The sensitivity and specificity are slightly lower than those quoted for diagnosis of blunt TDI, as detailed above. As with all CT scans, the main risks are associated with radiation exposure and intravenous contrast. A negative CT scan may also falsely reassure the provider that a TDI is not present and thus must be interpreted with the appropriate caution. Finally, CT imaging also has limited diagnostic utility for hemodynamically unstable patients, as these patients usually proceed directly to the operating room without imaging.

Magnetic resonance imaging (MRI) has also been described as an option for non-invasive diagnosis of TDI, especially in patients without other significant traumatic injuries in whom the diagnosis remains doubtful (16). However, it is limited by its overall accessibility and increased time to obtain.

Invasive procedures play a large (and growing) part in the diagnosis of these injuries. Diagnostic peritoneal lavage has been shown to have low sensitivity for diagnosing diaphragmatic injury and is not recommended (2). However, DL has been shown in multiple studies to be an excellent tool for diagnosing TDI, especially related to penetrating trauma (17-19). In the Eastern Association for the Surgery of Trauma (EAST) 2018 guidelines, DL was noted to have a pooled sensitivity of 88–100%, with a pooled specificity of 100% (14). DL is especially helpful in hemodynamically stable patients with left-sided thoracoabdominal penetrating trauma, leading to the 2018 EAST guideline that conditionally recommends DL rather than CT scan in this specific population to decrease the incidence of missed TDI (20). Surgeons may still choose to proceed first with CT scan, however, if there is high suspicion for an extracavitary trajectory of the wound (21). The utility of DL for diagnosis of right-sided thoracoabdominal penetrating trauma remains unknown, as the risk of organ herniation is much lower due to the shielding effect of the liver. Thus, the EAST and the Western Trauma Association do not recommend further screening for injury with a DL in these patients after a negative CT scan (20,21). Algorithms addressing the diagnosis of acute TDI are presented in Figures 1,2.

Figure 1 Blunt TDI algorithm. ^a, such as hemodynamic instability, peritonitis, or evisceration of abdominal contents; ^b, laparoscopy versus robotic-assisted laparoscopy. CT, computed tomography; CXR, chest radiograph; IV, intravenous; TDI, traumatic diaphragmatic injury.

Figure 2 Penetrating TDI algorithm. ^a, such as hemodynamic instability, peritonitis, or evisceration of abdominal contents; ^b, laparoscopy versus robotic-assisted laparoscopy. CT, computed tomography; CXR, chest radiograph; IV, intravenous; TDI, traumatic diaphragmatic injury.

Similarly, video-assisted thoracoscopy has also been shown to be an accurate tool for diagnosing TDI (2). In fact, some studies have found thoracoscopy to be potentially better than laparoscopy for posterior and right-sided TDI (14). However, it is used less frequently than DL among acute care surgeons, reportedly due to the patient positioning necessary and occasional inability to repair the diaphragm through the thorax (2). Thoracoscopy may also prove disadvantageous if the TDI is associated with significant injuries to abdominal organs that require repair or resection.

Grading of diaphragmatic injury

As with most traumatic injuries, grading of injury should follow diagnosis. The Organ Injury Scaling Committee of the American Association for the Surgery of Trauma has provided a classification system for diaphragmatic injuries, ranging from grade I to V (22).

• Grade I defines a diaphragmatic contusion;
• Grade II involves a laceration less than 2 cm;
• Grade III defines a laceration from 2–10 cm;
• Grade IV involves a laceration larger than 10 cm with tissue loss less than 25 cm²;
• Grade V defines a laceration leading to tissue loss >25 cm²;

Of note, in this system, bilateral injuries advance one grade, up to grade III.

Management of diaphragm injuries

There are several approaches to the management of TDI. Multiple organizations have published guidelines on this topic; however, as this is an uncommon injury, the approach to management is always evolving. Several factors should be considered regarding the operative management of TDI. The first aspect to consider is the acuity of the injury. The second aspect that can affect operative management is whether the injury is secondary to a blunt or penetrating mechanism. Finally, hemodynamics can influence choice of operative management, especially in the acute setting. Figures 1,2 provide general algorithms regarding diagnosis and management of acute TDI, the details of which are discussed extensively below.

The published guidelines regarding TDI management include the EAST, the World Society of Emergency Surgery (WSES), and the most recent guidelines from the Western Trauma Association. These guidelines promote an abdominal approach in the acute setting. The advantage of the abdominal approach is the ability to manage other intraabdominal injuries that may be present. Exploratory laparotomy is the most common approach for acute TDI repair. A 2010 literature review demonstrated that 74% of TDI were repaired via laparotomy, 18% by thoracotomy, and 8% by a thoracoabdominal approach (9). However, minimally invasive techniques have been demonstrated to be safe in certain patient populations. Over a 15-year period of reviewed cases in Wisconsin, laparotomy was still the most common approach; however, in the later years, there was increasing use of minimally invasive surgical techniques (3). Both EAST and WSES guidelines recommend laparoscopy in hemodynamically stable patients (20,23). In penetrating thoracoabdominal injuries, laparoscopy is often used for diagnostic purposes, especially when other intraabdominal injuries are not suspected. If an injury is identified, it can be repaired via this technique. The advantage of a minimally invasive technique is a decrease in hospital length of stay (14). Recently, robotic-assisted laparoscopic diaphragm repair has been described. In a newer case report, a 10 cm × 2 cm left-sided diaphragm defect was repaired using the robotic platform in a hemodynamically stable patient (24). While not as common, there may be times in the acute setting when a thoracic approach is more beneficial. For example, if a thoracotomy is necessary, the diaphragm injury can be repaired at the same time. Similarly to the abdominal approach, minimally invasive thoracic approaches have been described. Video-assisted thoracoscopic surgery (VATS) has been used to repair the diaphragm of hemodynamically stable patients in the setting of a hemothorax or pneumothorax (9,12). VATS is beneficial for posterior and right-sided injuries, as the liver can make intraabdominal visualization difficult (25). Disadvantages of this technique include the positioning of the patient in a lateral decubitus position, single lung ventilation, and the need for thoracoscopic suturing (12). Due to these concerns, patient selection is of the utmost importance.

Surgical technique

Acute diaphragm injury

When it comes to surgical technique, the basic principles of injury management apply. First, the extent of the injury should be determined. If there is any devitalized tissue, this should be debrided; then, a tension-free repair should be performed. Most commonly, larger injuries are repaired with No. 0 or 1 non-absorbable suture, either braided or monofilament. This has been described in continuous, figure-of-eight, and horizontal mattress fashion (4,7,12,26). Some surgeons employ a two-layer closure for larger (greater than 2 cm) defects, utilizing an interlocking horizontal mattress suture with an outer running 3-0 non-absorbable suture (7). Others have described using absorbable sutures for smaller TDI that are associated with penetrating injuries (3). As newer sutures have developed, their use has been described in acute TDI. A 2017 case report describes using 3-0 V-loc (absorbable suture with self-locking barbs) with a hemoclip on one end to repair a 2 cm TDI (26). Another case report describes closing a larger injury (4 cm × 3 cm) with 0 V-loc, laparoscopically (27). The advantage of this suture is that no knots are required, which avoids the difficulty of tying in a deep hole. Pledgets have been described in the repair of diaphragm injuries, especially when a reduction in tearing of the muscle is desired (12,26).

With regards to the use of mesh, the WSES gives a weak recommendation for its use in the acute setting. A mesh may be considered for very large defects that cannot be closed primarily (23). Synthetic mesh is less frequently used in the acute setting due to the associated contamination from perforated hollow viscous structures. If there is contamination associated with the injury, a biological or synthetic absorbable mesh should be considered. For larger defects or diaphragm disruption from the lateral chest wall, techniques described include transposing the diaphragm to higher ribs if there is a loss of tissue (28), or suturing directly to the ribs (7). Prior to the closure of the defect, copious irrigation should be performed. This is especially important in the setting of an associated perforated viscous, to prevent infection in that space (7). Finally, a thoracostomy tube should be placed in the chest if it was not placed at the beginning of the case. The thoracostomy tube should ideally be placed prior to pneumoperitoneum for minimally invasive repairs to prevent any difficulties in anesthetic complications (26).

Chronic diaphragm hernia

While repair in the acute setting is recommended, diaphragm injuries can be missed and require delayed repair. Chronic traumatic diaphragm hernia (TDH) can present incidentally on imaging for other reasons, or they can present emergently with incarceration or strangulation of the hernia contents in a patient with a remote history of trauma. Similarly to the acute setting, several factors will determine the operative management, including an abdominal versus thoracic approach and a minimally invasive versus open technique. When a patient presents with incarceration/strangulation, this is a surgical emergency (7). Several studies note that in the emergent presentation, the abdominal approach is best. With this approach, the abdominal organs that are involved can be examined and managed in an easier fashion than via a thoracic approach (21,23,29).

Unlike acute traumatic diaphragm injuries, chronic hernias are less common and, therefore, there is less consensus on their management. The 2018 EAST guidelines on diaphragm injury could not make a recommendation regarding the best management technique for chronic TDH. There was only one study that compared thoracic versus abdominal approach, but the number of patients was low. In this study, there were no differences in outcomes except for a higher rate of pneumonia seen in the thoracic approach (30). However, in an elective setting, a thoracic approach may be easier technically, as the thoracic cavity may be free of adhesions from the initial injury and/or provide a better visualization of pleural-visceral adhesions (23). Another case report described additional rib plating for displaced rib fractures, and this influenced the decision to pursue a thoracotomy approach (11). Several studies note that chronic right-sided diaphragmatic hernias can be repaired via a right thoracotomy at the 6^th or 7^th intercostal space. The liver usually inhibits the abdominal approach for these right-sided hernias; proceeding with a thoracotomy incision allows a decortication to be performed, as well as adhesions between the viscera, chest wall and lung to be freed (31). In the EAST guidelines, diaphragmatic injuries were repaired using an abdominal approach in 54.5% of patients, via a thoracic approach in 35.2% of patients, and using a combined abdominal and thoracic approach in 10% of patients (20). This is a higher utilization of the thoracic approach.

As surgeons have become more facile with minimally invasive techniques, there has been an increase in its usage for chronic TDH. A group reported in 2016 that 5/19 (26%) of their chronic diaphragm hernias were repaired laparoscopically (32), while 6 years later, another group reported 9/14 (64%) were repaired in a minimally invasive fashion (33). Sometimes, due to the adhesions, both thoracoscopic and laparoscopic techniques may be needed. Similarly to acute repairs, the same technical considerations need to be considered for the repair. The suture most often used is either monofilament or braided non-absorbable (23). A review of laparoscopically repaired chronic TDH demonstrated that 60% were repaired with sutures only, 30% with mesh, and 10% with both sutures and mesh (32). Another group reports placing mesh on any hernia greater than 3 cm (33). Usually, in the elective setting, there isn’t a concurrent visceral injury; therefore, synthetic mesh can be placed. The WSES guidelines suggest using polytetrafluoroethylene (PTFE Gore-Tex, Gore & Assoc, Arizona, USA) because it is often used in diaphragm reconstruction and does not adhere to the bowel as easily as other meshes. Another recommendation from the WSES guidelines is not to remove the hernia sac during repair of chronic TDH. The guidelines reference that retention of the hernia sac has no obvious complication; however, if the sac is removed, there is potential for pneumomediastinum, damage to pericardium, or other mediastinal structures. The possible benefits noted of sac removal would be decreased tissue trauma, especially if organs are within the sac. Other potential benefits of sac removal would be a decreased chance of symptomatic fluid collection and a decreased chance that the remaining sac would act as a lead for point recurrence (23). Of note, this guideline is graded as weak, and the surgeon should assess each patient with chronic TDH individually when deciding on hernia sac removal. A chest tube is optional during chronic TDH repair, and the need for placement can be determined at any point throughout the operation. As the hernia sac is well developed in chronic TDH, if the pleural space is not violated (such as during transabdominal approach), and no lung injury is noted, then a chest tube is not needed. If using a thoracotomy/thoracoscopic approach, a chest tube is usually placed, as the pleural space is violated (26).

Complications of repair

Several studies have examined complications related to TDI repair. D’souza et al. reported a 23% rate of complications such as surgical site infections, nosocomial pneumonia, or atelectasis. In 17% of patients, there was retained hemothorax, recurrent pneumothorax after chest tube removal, empyema, or biloma due to a liver injury. They noted that 15% of patients required surgical interventions due to pulmonary lobar collapse, bile leak, abdominal evisceration, iatrogenic injury, anastomotic leak, intraabdominal abscess, or a missed injury (4). Other complications can be related to viscera perforating into the thoracic cavity. These complications are pneumonia, empyema, and subphrenic or intraabdominal abscesses. This is why vigorous irrigation of the abdominal and thoracic cavities is recommended (9). Other less common complications include phrenic nerve and abdominal compartment syndrome after the reduction of contents into the abdomen from the chest (12). Finally, hernia recurrence is always a possibility. However, long-term follow-up is lacking in this patient population. In several studies of chronic TDH repair, no hernia recurrences were noted with a median follow-up of 15 months and 2 years (32,33).

Strength and limitations

This review focused upon the most recent literature in this arena, providing up-to-date information on an injury that has seen extensive changes in diagnosis and management over the years. Detailed algorithms regarding the diagnosis and management of TDI were provided. However, this review is limited in that TDI is an uncommon injury, with overall low quality of evidence in existence secondary to a relatively low number of affected patients. No randomized controlled trials regarding diagnosis or management of TDI currently exist. As such, multicenter collaboration and tracking of TDI offers an opportunity to address the significant evidence gap.

Conclusions

TDI remains a difficult injury to diagnose due to the wide range of presenting symptoms. Unfortunately, injuries to the diaphragm do not heal spontaneously and thus a high index of suspicion must be maintained to assure diagnosis. Invasive modalities such as DL and thoracoscopy are important diagnostic tools in the armamentarium of the acute care surgeon. Surgical repair varies widely in approach, suture material, and use of mesh.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Christopher F. Janowak) for the series “Chest Trauma” published in Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-13/rc

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-13/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-13/coif). The series “Chest Trauma” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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