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Imaging of Diaphragmatic Injury: A Diagnostic Challenge?¹

¹ From the Department of Radiology "Imagerie Guilloz" (S.I., T.L., F.W., A.G.B.) and Department of Surgery (H.S., G.G.), Hôpital Central, 29 Avenue de Lattre de Tassigny, 54035 Nancy, France. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 27, 2002; revision requested April 1; final revision received June 14; accepted June 19. Address correspondence to S.I. (e-mail: s.iochum@chu-nancy.fr).

View larger version (106K): [in a new window]   Figure 1.  Normal anatomy of the diaphragm. Drawing shows the central tendon (arrow) and the crura (arrowheads). IVC = aperture for the inferior vena cava.

View larger version (128K): [in a new window]   Figure 2.  Normal appearance of the posterior diaphragm. CT scan clearly shows the crura in the direct axial plane (arrows).

View larger version (137K): [in a new window]   Figure 3.  Anatomy of the posterior diaphragm. CT scan shows the left arcuate ligament in the direct axial plane (arrowhead). The crura are also seen (arrows).

View larger version (144K): [in a new window]   Figure 4.  CT scan (direct axial section) of the anterior diaphragm shows incomplete visibility of the diaphragm where it abuts structures of similar attenuation, such as the liver (bottom arrow). The hemidiaphragms are well demonstrated when they are marginated by peritoneal, retroperitoneal, or extraperitoneal fat (top arrow).

View larger version (115K): [in a new window]   Figure 5a.  Configurations of the anterior diaphragm as described by Gale (4). (a) CT scan shows the type 1 configuration. The anterior component is concave posteriorly and continuous with the anterolateral diaphragmatic fibers (arrowheads). (b) CT scan shows the type 2 configuration. The anterior muscle fibers appear to be oriented at an angle in relation to the lateral fibers with midline discontinuity (arrowhead). (c) CT scan shows the type 3 configuration. The anterior muscle fibers lie anteriorly within a single plane.

View larger version (112K): [in a new window]   Figure 5b.  Configurations of the anterior diaphragm as described by Gale (4). (a) CT scan shows the type 1 configuration. The anterior component is concave posteriorly and continuous with the anterolateral diaphragmatic fibers (arrowheads). (b) CT scan shows the type 2 configuration. The anterior muscle fibers appear to be oriented at an angle in relation to the lateral fibers with midline discontinuity (arrowhead). (c) CT scan shows the type 3 configuration. The anterior muscle fibers lie anteriorly within a single plane.

View larger version (87K): [in a new window]   Figure 5c.  Configurations of the anterior diaphragm as described by Gale (4). (a) CT scan shows the type 1 configuration. The anterior component is concave posteriorly and continuous with the anterolateral diaphragmatic fibers (arrowheads). (b) CT scan shows the type 2 configuration. The anterior muscle fibers appear to be oriented at an angle in relation to the lateral fibers with midline discontinuity (arrowhead). (c) CT scan shows the type 3 configuration. The anterior muscle fibers lie anteriorly within a single plane.

View larger version (158K): [in a new window]   Figure 6.  CT scan shows that the diaphragm is not well demonstrated due to the proximity of the liver, which has the same attenuation. Note the diaphragmatic slips that attach to the ribs (arrowheads).

View larger version (106K): [in a new window]   Figure 7.  Sites of injuries. Drawing shows radial (A), transverse (B), and central (C) ruptures and a peripheral detachment (D). Radial tears appear to be the most frequently found injury at surgery, whereas peripheral detachments are the least frequent.

View larger version (171K): [in a new window]   Figure 8.  Left diaphragmatic tear in a 24-year-old woman who was injured in a motor vehicle accident. Initial chest radiograph shows intrathoracic herniation of the stomach (S), a pleural effusion, a pulmonary contusion, and contralateral mediastinal shift.

View larger version (166K): [in a new window]   Figure 9.  Left diaphragmatic tear in a 48-year-old man after a motor vehicle accident. Initial chest radiograph shows a gas-filled viscus above the left hemidiaphragm that corresponds to the colon (C). A nasogastric tube is clearly seen in the thoracic cavity (arrow).

View larger version (158K): [in a new window]   Figure 10a.  Left diaphragmatic tear in a 65-year-old patient after blunt trauma. S = stomach. (a) CT scan obtained at the level of the hepatic hilum shows a defect in the continuity of the anterolateral left hemidiaphragm (arrows). C = colon. (b) CT scan of the midthoracic region shows intrathoracic herniation of the stomach. (c, d) Sagittal (c) and coronal (d) reformatted images show the intrathoracic herniation of the stomach more clearly. (e) Image from laparoscopy shows the intrathoracic herniation of the stomach and the diaphragmatic tear.

View larger version (141K): [in a new window]   Figure 10b.  Left diaphragmatic tear in a 65-year-old patient after blunt trauma. S = stomach. (a) CT scan obtained at the level of the hepatic hilum shows a defect in the continuity of the anterolateral left hemidiaphragm (arrows). C = colon. (b) CT scan of the midthoracic region shows intrathoracic herniation of the stomach. (c, d) Sagittal (c) and coronal (d) reformatted images show the intrathoracic herniation of the stomach more clearly. (e) Image from laparoscopy shows the intrathoracic herniation of the stomach and the diaphragmatic tear.

View larger version (139K): [in a new window]   Figure 10c.  Left diaphragmatic tear in a 65-year-old patient after blunt trauma. S = stomach. (a) CT scan obtained at the level of the hepatic hilum shows a defect in the continuity of the anterolateral left hemidiaphragm (arrows). C = colon. (b) CT scan of the midthoracic region shows intrathoracic herniation of the stomach. (c, d) Sagittal (c) and coronal (d) reformatted images show the intrathoracic herniation of the stomach more clearly. (e) Image from laparoscopy shows the intrathoracic herniation of the stomach and the diaphragmatic tear.

View larger version (148K): [in a new window]   Figure 10d.  Left diaphragmatic tear in a 65-year-old patient after blunt trauma. S = stomach. (a) CT scan obtained at the level of the hepatic hilum shows a defect in the continuity of the anterolateral left hemidiaphragm (arrows). C = colon. (b) CT scan of the midthoracic region shows intrathoracic herniation of the stomach. (c, d) Sagittal (c) and coronal (d) reformatted images show the intrathoracic herniation of the stomach more clearly. (e) Image from laparoscopy shows the intrathoracic herniation of the stomach and the diaphragmatic tear.

View larger version (92K): [in a new window]   Figure 10e.  Left diaphragmatic tear in a 65-year-old patient after blunt trauma. S = stomach. (a) CT scan obtained at the level of the hepatic hilum shows a defect in the continuity of the anterolateral left hemidiaphragm (arrows). C = colon. (b) CT scan of the midthoracic region shows intrathoracic herniation of the stomach. (c, d) Sagittal (c) and coronal (d) reformatted images show the intrathoracic herniation of the stomach more clearly. (e) Image from laparoscopy shows the intrathoracic herniation of the stomach and the diaphragmatic tear.

View larger version (116K): [in a new window]   Figure 11a.  Right diaphragmatic tear in a 46-year-old man who experienced multiple injuries in a motor vehicle accident. (a) CT scan shows a subtle sign of a right diaphragmatic tear: a focal indentation in the posterolateral aspect of the liver with a contusion (arrow). (b) Coronal reformatted image clearly shows a waistlike constriction of the liver (arrowheads). (c) Coronal contrast material-enhanced fat-suppressed fast gradient-echo MR image shows a high position of the liver in the thoracic cavity. The constricting rim of the diaphragm is seen as a low-signal-intensity structure around the herniated liver (arrowheads).

View larger version (109K): [in a new window]   Figure 11b.  Right diaphragmatic tear in a 46-year-old man who experienced multiple injuries in a motor vehicle accident. (a) CT scan shows a subtle sign of a right diaphragmatic tear: a focal indentation in the posterolateral aspect of the liver with a contusion (arrow). (b) Coronal reformatted image clearly shows a waistlike constriction of the liver (arrowheads). (c) Coronal contrast material-enhanced fat-suppressed fast gradient-echo MR image shows a high position of the liver in the thoracic cavity. The constricting rim of the diaphragm is seen as a low-signal-intensity structure around the herniated liver (arrowheads).

View larger version (125K): [in a new window]   Figure 11c.  Right diaphragmatic tear in a 46-year-old man who experienced multiple injuries in a motor vehicle accident. (a) CT scan shows a subtle sign of a right diaphragmatic tear: a focal indentation in the posterolateral aspect of the liver with a contusion (arrow). (b) Coronal reformatted image clearly shows a waistlike constriction of the liver (arrowheads). (c) Coronal contrast material-enhanced fat-suppressed fast gradient-echo MR image shows a high position of the liver in the thoracic cavity. The constricting rim of the diaphragm is seen as a low-signal-intensity structure around the herniated liver (arrowheads).

View larger version (97K): [in a new window]   Figure 12a.  Right diaphragmatic tear in a 35-year-old man after a motor vehicle accident. (a) Helical CT scan (direct axial section) shows a focal indentation at the posterolateral aspect of the liver (arrow), a finding suggestive of a right diaphragmatic tear. (b) Coronal reformatted image shows elevation and focal constriction of the liver. (c) Sagittal single-shot fast spin-echo MR image clearly shows the posterior diaphragm (arrow), which is outlined by hemoperitoneum and pleural effusion. (d) Coronal contrast-enhanced fast gradient-echo MR image clearly shows waistlike constriction of the liver at the level of the diaphragmatic tear.

View larger version (115K): [in a new window]   Figure 12b.  Right diaphragmatic tear in a 35-year-old man after a motor vehicle accident. (a) Helical CT scan (direct axial section) shows a focal indentation at the posterolateral aspect of the liver (arrow), a finding suggestive of a right diaphragmatic tear. (b) Coronal reformatted image shows elevation and focal constriction of the liver. (c) Sagittal single-shot fast spin-echo MR image clearly shows the posterior diaphragm (arrow), which is outlined by hemoperitoneum and pleural effusion. (d) Coronal contrast-enhanced fast gradient-echo MR image clearly shows waistlike constriction of the liver at the level of the diaphragmatic tear.

View larger version (142K): [in a new window]   Figure 12c.  Right diaphragmatic tear in a 35-year-old man after a motor vehicle accident. (a) Helical CT scan (direct axial section) shows a focal indentation at the posterolateral aspect of the liver (arrow), a finding suggestive of a right diaphragmatic tear. (b) Coronal reformatted image shows elevation and focal constriction of the liver. (c) Sagittal single-shot fast spin-echo MR image clearly shows the posterior diaphragm (arrow), which is outlined by hemoperitoneum and pleural effusion. (d) Coronal contrast-enhanced fast gradient-echo MR image clearly shows waistlike constriction of the liver at the level of the diaphragmatic tear.

View larger version (139K): [in a new window]   Figure 12d.  Right diaphragmatic tear in a 35-year-old man after a motor vehicle accident. (a) Helical CT scan (direct axial section) shows a focal indentation at the posterolateral aspect of the liver (arrow), a finding suggestive of a right diaphragmatic tear. (b) Coronal reformatted image shows elevation and focal constriction of the liver. (c) Sagittal single-shot fast spin-echo MR image clearly shows the posterior diaphragm (arrow), which is outlined by hemoperitoneum and pleural effusion. (d) Coronal contrast-enhanced fast gradient-echo MR image clearly shows waistlike constriction of the liver at the level of the diaphragmatic tear.

View larger version (155K): [in a new window]   Figure 13a.  Dependent viscera sign in a 28-year-old pregnant woman after a motor vehicle accident. (a) CT scan (direct axial section) shows intrathoracic herniation of the stomach and colon owing to left diaphragmatic rupture, a hepatic hematoma, and a pleural effusion. Note the dependent viscera sign. (b) Sagittal reformatted image shows a deformity of the aortic contour and an isthmic intimal flap, which indicate an aortic injury.

View larger version (163K): [in a new window]   Figure 13b.  Dependent viscera sign in a 28-year-old pregnant woman after a motor vehicle accident. (a) CT scan (direct axial section) shows intrathoracic herniation of the stomach and colon owing to left diaphragmatic rupture, a hepatic hematoma, and a pleural effusion. Note the dependent viscera sign. (b) Sagittal reformatted image shows a deformity of the aortic contour and an isthmic intimal flap, which indicate an aortic injury.

View larger version (154K): [in a new window]   Figure 14a.  Diaphragmatic defects in a 68-year-old patient. CT scans (direct axial sections) show diaphragmatic defects (arrow) of the right (a) and left (b) posterolateral hemidiaphragms.

View larger version (153K): [in a new window]   Figure 14b.  Diaphragmatic defects in a 68-year-old patient. CT scans (direct axial sections) show diaphragmatic defects (arrow) of the right (a) and left (b) posterolateral hemidiaphragms.

View larger version (153K): [in a new window]   Figure 15a.  Isolated elevation of the diaphragm in a 59-year-old man after blunt trauma. (a, b) CT scan (a) and sagittal reformatted image (b) show an isolated elevation of the diaphragm (arrow) without discontinuity. Note the right-sided rib fracture on the scan (a). (c, d) Sagittal single-shot fast spin-echo (c) and contrast-enhanced fat-suppressed fast gradient-echo (d) MR images show the diaphragm (arrow) as a thin hypointense band. Fat suppression and contrast enhancement (d) are used for better demonstration of the diaphragm and for differentiation between a pleural effusion and a pulmonary contusion or atelectasis (arrowhead).

View larger version (161K): [in a new window]   Figure 15b.  Isolated elevation of the diaphragm in a 59-year-old man after blunt trauma. (a, b) CT scan (a) and sagittal reformatted image (b) show an isolated elevation of the diaphragm (arrow) without discontinuity. Note the right-sided rib fracture on the scan (a). (c, d) Sagittal single-shot fast spin-echo (c) and contrast-enhanced fat-suppressed fast gradient-echo (d) MR images show the diaphragm (arrow) as a thin hypointense band. Fat suppression and contrast enhancement (d) are used for better demonstration of the diaphragm and for differentiation between a pleural effusion and a pulmonary contusion or atelectasis (arrowhead).

View larger version (136K): [in a new window]   Figure 15c.  Isolated elevation of the diaphragm in a 59-year-old man after blunt trauma. (a, b) CT scan (a) and sagittal reformatted image (b) show an isolated elevation of the diaphragm (arrow) without discontinuity. Note the right-sided rib fracture on the scan (a). (c, d) Sagittal single-shot fast spin-echo (c) and contrast-enhanced fat-suppressed fast gradient-echo (d) MR images show the diaphragm (arrow) as a thin hypointense band. Fat suppression and contrast enhancement (d) are used for better demonstration of the diaphragm and for differentiation between a pleural effusion and a pulmonary contusion or atelectasis (arrowhead).

View larger version (134K): [in a new window]   Figure 15d.  Isolated elevation of the diaphragm in a 59-year-old man after blunt trauma. (a, b) CT scan (a) and sagittal reformatted image (b) show an isolated elevation of the diaphragm (arrow) without discontinuity. Note the right-sided rib fracture on the scan (a). (c, d) Sagittal single-shot fast spin-echo (c) and contrast-enhanced fat-suppressed fast gradient-echo (d) MR images show the diaphragm (arrow) as a thin hypointense band. Fat suppression and contrast enhancement (d) are used for better demonstration of the diaphragm and for differentiation between a pleural effusion and a pulmonary contusion or atelectasis (arrowhead).

View larger version (129K): [in a new window]   Figure 16a.  Motion artifact in a 28-year-old woman who was involved in a motor vehicle accident. Coronal (a) and sagittal (b) CT reformatted images show an apparent isolated liver herniation due to motion artifact, which could mimic a diaphragmatic tear.

View larger version (95K): [in a new window]   Figure 16b.  Motion artifact in a 28-year-old woman who was involved in a motor vehicle accident. Coronal (a) and sagittal (b) CT reformatted images show an apparent isolated liver herniation due to motion artifact, which could mimic a diaphragmatic tear.

View larger version (138K): [in a new window]   Figure 17a.  Motion artifacts in a 55-year-old woman who was involved in a motor vehicle accident. (a) Coronal CT reformatted image shows motion artifacts. (b) Coronal reformatted image from a shorter CT acquisition with thicker collimation and adequate breath holding shows an intact right hemidiaphragm.

View larger version (118K): [in a new window]   Figure 17b.  Motion artifacts in a 55-year-old woman who was involved in a motor vehicle accident. (a) Coronal CT reformatted image shows motion artifacts. (b) Coronal reformatted image from a shorter CT acquisition with thicker collimation and adequate breath holding shows an intact right hemidiaphragm.