Physiotherapy Management of Traumatized Diaphragm

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Introduction

The diaphragm is a double-domed musculoskeletal partition separating the thoracic and abdominal cavities. It is very crucial for respiration and maintenance of intra-abdominal pressure, and injuries can result in significant ventilatory compromise. Traumatic diaphragmatic injuries (TDI) include wounds and diaphragm ruptures, due to thoraco-abdominal blunt or penetrating traumas (Thiam et al, 2016). Paré in 1579, first made  a description of diaphragmatic rupture in a french artillery captain, who initially survived a gunshot wound of the abdomen, but died 8 months later of a strangulated gangrenous colon, herniated through a small diaphragmatic defect that would admit only the tip of the finger (Bhatia et al, 2008). It was not until the end of the nineteenth century that surgical procedures for this condition were being undertaken. Despite having been recognised early in the history of surgery, blunt traumatic diaphragm rupture was a rarely reported condition before the twentieth century.

Traumatic diaphragmatic injuries are usually occult and can easily be missed. They occur in a context of multiple trauma (Bosanquet et al. 2009) making diagnosis difficult. In developing countries where initial care of severely injured patients and diagnostic facilities are less than optimal, blunt TDI may go undiagnosed (Kidmas et al, 2005). An accurate diagnosis requires a high index of suspicion as missed TDI may result in herniation and strangulation of intra-abdominal viscera into the thoracic cavity (Petrone et al, 2007). This herniation can interfere with breathing, and blood supply can be cut off to organs that herniated through the diaphragm, damaging them (Senent-B0za et al, 2015).

Etiology

Traumatic diaphragmatic injuries may be caused by blunt trauma, penetrating trauma, and iatrogenic causes, for example during surgery to the abdomen or chest. Penetrating trauma with direct injury to the diaphragm is more common and accounts for about two-thirds of cases. It is frequently caused by gunshot injuries, stab wounds or impalement lesions (Morgan et al, 2010). For blunt trauma, road traffic accidents and falls from height are the most common causes (Kidmas et al, 2005; Scharff and Naunheim, 2007).

Clinicians are trained to suspect diaphragmatic rupture particularly if penetrating trauma has occurred to the lower chest or upper abdomen (Asensio et al, 2003). With penetrating trauma, the contents of the abdomen may not herniate into the chest cavity right away, but they may do so later, causing the presentation to be delayed (Scharff and Naunheim, 2007). Since the diaphragm moves up and down during breathing, penetrating trauma to various parts of the torso may injure the diaphragm (Fleisher and Ludwig, 2010). In some extremely rare case, the patient may have phrenic nerve injury leading to diaphragmatic paralysis

Incidence and Epidemiology

The Incidence of TDI ranges from 0.8 to 8%, but the true incidence is likely to be higher due to missed or delayed diagnosis (Lopez et al, 2010). Traumatic diaphragmatic injuries can be missed even during exploratory surgery; with one series demonstrating 14% of TDI missed at an initial laparatomy (Esme et al, 2006). This is likely due to the lack of a high index suspicion and the difficulty with direct visualization of the hemi-diaphragms (DeBarros and Martin, 2015).

Penetrating TDI is highest among thoraco-abdominal gunshot wounds (DeBarros and Martin, 2015). It accounts for 5 to 10% of admissions at most trauma centers (Lopez et al, 2010; Zarour et al, 2013). While most blunt TDI are located in the central or posterolateral diaphragm and are related to embryologic weakness, penetrating TDI can occur anywhere on the diaphragm (Dirican et al, 2011).

Left-sided TDI is more common, representing 75% of cases (Hanna and Ferri, 2009). Right-sided TDI is less common with most series reporting rates of 35-49%, however, they are much harder to diagnose due to coverage by the liver, and the true incidence is almost certainly higher than reported (DeBarros and Martin, 2015). Left-sided TDI have more frequent Injuries to associated organs, and have a higher morbidity and mortality risk (Zarour et al, 2013). Bilateral TDI is an extremely rare occurrence, reported as 2 to 8% overall but is seen almost exclusively with blunt mechanisms (Ties et al, 2014).

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