AJR 2005; 184:24-30
© American Roentgen Ray Society
Helical CT of Blunt Diaphragmatic Rupture
Alain Nchimi1,2,
David Szapiro1,
Benoît Ghaye1,
Valérie Willems1,
Jamil Khamis2,
Luc Haquet2,
Charlemagne Noukoua1 and
Robert F. Dondelinger1
1 Department of Medical Imaging, University Hospital Sart Tilman, B-4000
Liège, Belgium.
2 Department of Medical Imaging, Centre Hospitalier Chrétien, Les
Cliniques St.-Joseph, Rue de Hesbaye, 75, B-4000 Liège, Belgium.
Received February 19, 2004;
accepted after revision June 30, 2004.
Address correspondence to A. Nchimi
(alain.nchimi{at}chc-liege.be).
Abstract
OBJECTIVE. This study evaluated CT findings for signs of blunt
diaphragmatic rupture.
MATERIALS AND METHODS. CT examinations of 179 blunt trauma patients,
including 11 with left-sided and five with right-sided blunt diaphragmatic
rupture, were reviewed by two staff radiologists who first decided by
consensus on the presence or absence of 11 published signs of blunt
diaphragmatic rupture and then formulated the diagnosis in terms of absence
of, presence of, or suggestion of blunt diaphragmatic rupture. The
significance of the findings was assessed by multivariate logistic regression.
Four other reviewers interpreted the CT findings independently. They were
asked first to formulate a diagnosis in terms of absence of, presence of, or
suggestion of blunt diaphragmatic rupture and then to enumerate the findings
supporting a diagnosis or suggestion of blunt diaphragmatic rupture. These
findings were compared with those of the staff radiologists.
RESULTS. Diaphragmatic discontinuity, diaphragmatic thickening,
segmental nonrecognition of the diaphragm, intrathoracic herniation of
abdominal viscera, elevation of the diaphragm, and both hemothorax and
hemoperitoneum were strong predictors of blunt diaphragmatic rupture
(p < 0.001). The combination of the first three findings was 100%
sensitive (16/16). The staff radiologists' sensitivity for diagnosing blunt
diaphragmatic rupture was 100% (16/16). The four reviewers' sensitivities were
56.2% (9/16), 81.2% (13/16), 62.5% (10/16), and 87.5% (14/16).
CONCLUSION. Six of 11 signs were good predictors of blunt
diaphragmatic rupture. Despite diaphragmatic thickening, focal defect and
segmental nonrecognition had 100% cumulative sensitivity; the reviewers
formulating the diagnosis before analyzing CT signs overlooked blunt
diaphragmatic rupture on CT in 12.5–43.8% of the patients.
Introduction
Blunt diaphragmatic rupture is present in 3–8% of patients undergoing
emergency celiotomy after trauma
[1]. Blunt diaphragmatic
rupture rarely accounts for immediate mortality and may go clinically silent
until complications occur. Gastrointestinal strangulation and obstruction
complicating unrecognized diaphragmatic herniation may have a mortality rate
as high as 60% [2]. Although
many imaging techniques have proven useful for the diagnosis of blunt
diaphragmatic rupture
[3–6],
diaphragmatic injuries, especially those on the right side, most frequently
have remained undiagnosed on CT during the acute evaluation of trauma patients
[7–13].
The suspected reasons for poor CT results include the usually associated and
potentially distracting thoracic and abdominal injuries, lack of awareness of
blunt diaphragmatic rupture, and discreet abnormalities on axial CT slices.
Initial reports found CT to have a sensitivity (0–50%) lower than or
equal to that of chest radiography
[9,
14–17].
As a result, numerous signs indicating blunt diaphragmatic rupture have been
described in the literature during the past 10 years, with variable
significance [7,
8,
10–13,
18].
The purpose of this study was to objectively assess the reported CT signs
of blunt diaphragmatic rupture and their impact on observer performance in
diagnosis.
Materials and Methods
Patients
We searched the hospital registry for cases of surgically or autopsy-proven
diaphragmatic rupture from January 1995 to January 2002. Among 53 cases, 19
patients with penetrating injury and 18 patients with incomplete imaging were
excluded. Finally, CT, clinical, surgical, or autopsy data of 16 patients (13
men and three women; age range, 21–68 years; mean age, 38 years) with a
proven diagnosis of blunt diaphragmatic rupture, after a car crash (15
patients) or a fall from a height (one patient), were available for review.
Eleven patients had left-sided and five had right-sided blunt diaphragmatic
rupture; none had bilateral or pericardiophrenic injury. Two of the five
patients with right-sided blunt diaphragmatic rupture and five of those with
left-sided blunt diaphragmatic rupture were intubated with positive pressure
ventilation on or before arrival at the hospital. Associated thoracic or
intraabdominal injuries were found in 15 patients. Diaphragmatic injury was
diagnosed through CT in 11 patients: on the admission CT for eight and on
repeated CT (6–19 days later) for three (whose CT findings on admission
had erroneously been interpreted as negative for blunt diaphragmatic rupture).
In five patients, the diagnosis of blunt diaphragmatic rupture was established
only during surgery or autopsy.
An additional 163 consecutive patients (131 males and 32 females; age
range, 12–78 years; mean age, 35 years) who had sustained blunt
abdominal or thoracic trauma during the same period, with either a surgically
or an autopsy-proven normal diaphragm (98 patients) or at least 1 year of
follow-up without evidence of diaphragmatic injury on chest radiography or CT
(65 patients), served as true-negative cases (91.0% of all cases). Thus, a
prevalence of 9% for blunt diaphragmatic rupture was assumed. Intraabdominal
or thoracic injuries were found in 103 patients of the control group. Patient
consent was not required for this retrospective study.
CT Examinations
On admission, all 179 patients underwent helical CT (PQ 2000, upgraded to
PQ 5000, Philips) of the chest, the abdomen, or both according to a
standardized protocol. None of the patients received oral or rectal contrast
material. For all but four patients, scans of 5- to 10-mm collimation and 5-
to 8-mm reconstruction interval were obtained 70–120 sec after the start
of IV contrast administration, 2 mL/kg (Ultravist 300 [iopromide], Schering;
or Optiray 300 [ioversol] or Xenetix 300 [iobitridol], Guerbet), at a rate of
1.8–3 mL/sec. Images of the entire liver and base of the thorax printed
with soft window settings (level, 40 H; width, 450 H) were available for
review. For four patients of the control group, CT was performed only without
contrast enhancement. Images with large window settings (level, -600 H; width,
1,600 H) covering the region of interest were not printed regularly but were
also available for 12 patients of the control group.
CT Review
First, two staff radiologists who had at least 5 years' experience in
trauma radiology and no prior exposure to the patients together completed a
questionnaire on the presence or absence of 11 CT signs of rupture reported in
the literature [7,
8,
10–15,
18]: diaphragmatic
discontinuity; segmental nonrecognition of the diaphragm; herniation of
abdominal organs into the thoracic cavity; a waistlike appearance of herniated
organs at the level of the diaphragm, the so-called collar sign; abnormally
elevated abdominal organs; thickening of the diaphragm, the so-called curled
diaphragm sign; thoracic fluid abutting the intraabdominal viscera; absence of
interposition of lungs between the upper part of the abdominal organs and the
chest wall, the so-called dependent viscera sign; hemothorax and
hemoperitoneum; IV contrast medium extravasation at the level of the
diaphragm; and presumed laceration of the diaphragm by a fractured rib.
Extending chest radiographic findings to CT, we considered right-sided
abdominal organs abnormally elevated when visible 5 cm or more above the dome
of the left hemidiaphragm and left-sided abdominal organs abnormally elevated
when visible 4 cm or more above the dome of the right hemidiaphragm
[4]. Diaphragmatic thickening
was assessed by visual comparison with the contralateral hemidiaphragm at the
same level, as described by Leung et al.
[11]. To avoid considering the
variations in normal size of the crus, the staff radiologists were asked to
assess diaphragm thickness at least 10 mm from the midline. After reviewing
the signs, the staff radiologists were asked to describe, consistently, each
hemidiaphragm as normal, injured, or suggestive.
Then the CT findings were retrospectively interpreted by four reviewers
with no prior exposure to the patients who were unaware of the surgical and
autopsy findings. The reviewers included a third-year radiology resident
(reviewer 1), a thoracic radiologist (reviewer 2), and two abdominal
radiologists (reviewers 3 and 4). To assess the importance of reviewer
experience in the diagnosis of blunt diaphragmatic rupture, reviewers 2 and 4
had at least 5 years' experience in trauma radiology, whereas reviewers 1 and
3 were less experienced. Reviewers were asked to describe each hemidiaphragm
as ruptured, normal, or suggestive and thereafter to list explicitly all signs
supporting the positive or suggestive diagnoses.
Statistical Analysis
Using the findings of the staff radiologists, we calculated the sensitivity
and specificity for each sign of right and left blunt diaphragmatic rupture
for the entire patient population. Logistic regression analysis was used to
assess the significance of each sign and the contribution of the number of
signs to the diagnosis of blunt diaphragmatic rupture. Sensitivity and
specificity for the diagnosis of blunt diaphragmatic rupture were calculated
for the staff radiologists and the reviewers, suggestive findings being
considered positive for rupture. To compare the mean diagnostic performance of
the reviewers for each sign (i.e., the sensitivity and specificity with which
they depicted each sign) with that of the staff radiologists, the reviewers'
reported findings were formulated in terms that matched those of the
questionnaire. The Cochran Q test was used to compare the reviewers'
sensitivities for the diagnosis of blunt diaphragmatic rupture. Continuous
data are expressed as mean ± SD. A p value less than 0.05 was
considered to express a statistically significant difference. The software
used for statistical analysis was Systat 9.0 (Systat Software).
Results
Table 1 shows that for the
two staff radiologists, intrathoracic herniation of abdominal organs was the
most sensitive sign for left-sided blunt diaphragmatic rupture (90.9% [10/11])
(Fig. 1) and diaphragmatic
thickening, for right-sided blunt diaphragmatic rupture (100% [5/5]) (Figs.
2,
3A, and
3B). All left-sided ruptures
had either diaphragmatic discontinuity (5/11) or segmental nonrecognition of
the diaphragm (6/11). Combination of both signs with diaphragmatic thickening
resulted in 100% cumulative sensitivity (16/16) for rupture on both sides. The
collar sign and the dependent viscera sign were 100% specific (163/163) for
blunt diaphragmatic rupture. Contrast medium extravasation at the level of the
diaphragm (Fig. 4) and presumed
laceration by fractured ribs had 0% sensitivity (0/16). In addition to the
signs listed on the questionnaire, the staff radiologists described, for one
patient, a hypoattenuated hemidiaphragm associated with right-sided blunt
diaphragmatic rupture (Figs.
5A,
5B,
5C, and
5D). Sensitivity and
specificity for isolated signs ranged from 0% (0/16) to 75% (12/16) and from
91.4% (149/163) to 100% (163/163), respectively. Any positive finding
significantly increased the likelihood of blunt diaphragmatic rupture
(p < 0.001). Multivariate logistic regression found six signs to
be isolated good predictors (p < 0.001) of blunt diaphragmatic
rupture: diaphragmatic discontinuity, segmental unrecognized diaphragm,
intrathoracic herniation of abdominal content, elevated abdominal organs,
thickened diaphragm, and the presence of both hemothorax and hemoperitoneum.
The other signs were poor predictors of blunt diaphragmatic rupture
(p > 0.05). The staff radiologists diagnosed normal diaphragms in
154 patients, blunt diaphragmatic rupture in 14 patients (all true-positive
cases), and a suggestion of hemidiaphragm in 11 patients (including two
true-positive cases of right-sided blunt diaphragmatic rupture and nine
false-positive cases) (Figs. 4,
6A, and
6B), resulting in 100%
sensitivity (16/16) and 94.6% specificity (154/163).
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TABLE 1 Diagnostic Values of 11 Signs of Blunt Diaphragmatic Rupture Evaluated
by Two Staff Radiologists and Multiple Regression Analysis
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Fig. 1. —32-year-old man who sustained blunt trauma to torso.
Abdominal CT scan obtained after IV injection of contrast medium shows
herniation of upper part of stomach into chest, in contact with posterior
thoracic wall (arrow) and adjacent to pleural effusion
(asterisk). Left hemidiaphragm is not visible above abdominal fat
(arrowheads).
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Fig. 2. —43-year-old man who sustained abdominal blunt trauma.
Abdominal CT scan obtained after IV injection of contrast medium shows diffuse
thickening of right hemidiaphragm (arrows). This sign was only
indication of right-sided diaphragmatic rupture, which was confirmed at
surgery.
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Fig. 3A. —Abdominal CT scans obtained after IV injection of contrast
medium in 32-year-old man admitted after frontal impact during car crash.
Right hemidiaphragm is visualized over liver, thanks to fat interposition
(asterisk).
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Fig. 3B. —Abdominal CT scans obtained after IV injection of contrast
medium in 32-year-old man admitted after frontal impact during car crash.
Image at level inferior to A shows lateral discontinuity of right
hemidiaphragm (straight arrow), whereas anterior leaf is retracted
and thickened (arrowheads). Associated constriction (curved
arrow) of contused and partially herniated liver is present.
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Fig. 4. —36-year-old man after car crash. Abdominal CT scan obtained
after IV injection of contrast medium shows representative pitfall of CT for
diagnosis of blunt diaphragmatic rupture. Extensive splenic contusion and
massive hemoperitoneum are evident. Left subphrenic hematoma (arrows)
simulates diaphragmatic thickening. Linear extravasation of contrast material
is seen in contact with diaphragm (arrowheads). This patient was
diagnosed as having, or was suspected of having, left-sided blunt
diaphragmatic rupture by all reviewers. At surgery, no diaphragmatic rupture
was found.
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Fig. 5A. —Abdominal CT scans obtained after IV injection of contrast
medium via right common femoral vein in 27-year-old man who sustained
abdominal trauma during car crash. Image at level of celiac trunk shows crus
of right hemidiaphragm in contact with aorta (white arrowheads),
whereas posterior part is not visible (black arrowheads). Focal
infarct of right kidney (asterisk) is also seen.
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Fig. 5B. —Abdominal CT scans obtained after IV injection of contrast
medium via right common femoral vein in 27-year-old man who sustained
abdominal trauma during car crash. Image at level of liver hilum shows
hypoattenuated right diaphragmatic crus (arrows), hypoperfusion
complex of spleen, hemoperitoneum, and focal infarct of right kidney
(asterisk).
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Fig. 5C. —Abdominal CT scans obtained after IV injection of contrast
medium via right common femoral vein in 27-year-old man who sustained
abdominal trauma during car crash. Images at levels superior to B show
progressively thickened but normally attenuated right hemidiaphragm
(arrows).
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Fig. 5D. —Abdominal CT scans obtained after IV injection of contrast
medium via right common femoral vein in 27-year-old man who sustained
abdominal trauma during car crash. Images at levels superior to B show
progressively thickened but normally attenuated right hemidiaphragm
(arrows).
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Fig. 6A. —Axial CT scans obtained after IV contrast administration in
55-year-old man who sustained thoracoabdominal trauma during car crash. Image
of posteromedial part of left hemidiaphragm shows defect
(arrows).
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Fig. 6B. —Axial CT scans obtained after IV contrast administration in
55-year-old man who sustained thoracoabdominal trauma during car crash. Image
at level superior to A displays fully continuous left hemidiaphragm.
This patient illustrated another pitfall of CT for diagnosis of diaphragmatic
rupture. Staff radiologists considered findings suggestive of left-sided blunt
diaphragmatic rupture, whereas at surgery no diaphragmatic rupture was
found.
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Table 2 gives the four
reviewers' diagnostic scores for blunt diaphragmatic rupture. The Cochran
Q statistic was 4.55 (4 df), indicating no significant
differences between reviewers for sensitivity in the diagnosis of blunt
diaphragmatic rupture (p = 0.34).
Table 3 gives the mean
sensitivity and specificity with which the reviewers depicted the signs of
blunt diaphragmatic rupture.
Discussion
Because blunt diaphragmatic rupture occurs in fewer than 10% of
polytraumatized patients undergoing emergency laparotomy
[1], we have assumed a
prevalence of 9% in our study. Because of this relatively low percentage, it
is likely that any radiologist working in a trauma center may encounter
annually only a few cases. Despite systematic CT screening of thoracoabdominal
injuries in hemodynamically stable patients and the description of 11
different CT signs, reported diagnostic sensitivities for blunt diaphragmatic
rupture have been 42–90%
[7–10,
13]. Notwithstanding the fact
that blunt diaphragmatic rupture was diagnosed on CT at admission in only
eight (50%) of 16 patients in our institution, we noticed the reviewers to
have sensitivities (range, 56.2–87.5%) similar to those reported in the
literature. Thus, in a fully prospective evaluation, the diagnosis of blunt
diaphragmatic rupture remains challenging and subject to observer performance.
However, the staff radiologists' retrospective sign-by-sign review showed that
all cases of blunt diaphragmatic rupture were identifiable on the first search
for the signs. The main purposes of the current study were to determine how
frequently each sign of blunt diaphragmatic rupture is visible on CT and to
point out the importance of axial CT signs for the diagnosis of blunt
diaphragmatic rupture. We found that searching for any single sign is crucial
for the diagnosis, because finding any sign is linked to a significantly high
probability (p < 0.001) of blunt diaphragmatic rupture.
Despite the notorious difficulty of diagnosing right-sided blunt
diaphragmatic rupture, all cases were identified by the presence of
diaphragmatic thickening. Diaphragmatic injury correlates strongly with this
sign, because it represents either retraction of the leaves of the ruptured
diaphragm or muscular hematoma
[11]. However, as an isolated
finding, diaphragmatic thickening does not distinguish between injury that
requires surgical repair and partial-thickness diaphragmatic rupture. This
sign was falsely positive in eight patients in our study and associated with
retroperitoneal hematoma that involved the diaphragm (three on the left side
and five on the right side). Our observation suggests that in the absence of
retroperitoneal contusion, diaphragmatic thickening may be considered highly
suggestive of blunt diaphragmatic rupture, although because of the study
design, the four reviewers, unlike the staff radiologists, were not asked to
assess diaphragmatic thickening at least 10 mm from the midline. The result
was a high percentage of interpretation errors by the reviewers, confirming
the large variations in the normal crus thickness found by Larici et al.
[18]. Segmental nonrecognition
of the diaphragm associated with diaphragmatic discontinuity resulted in
identification of all cases of left-sided blunt diaphragmatic rupture. In six
patients, segmental nonrecognition of the diaphragm was not related to blunt
diaphragmatic rupture; the diaphragm was obscured by retroperitoneal hematoma
in four (67%) of the six, by hemoperitoneum in one (17%) of the six, and by
basal chest injuries in one (17%) of the six. Reviewer performance varied,
indicating that not all studied signs had equal diagnostic value.
The collar sign, the "dependent viscera" sign, and thoracic
fluid abutting the intraabdominal viscera were highly specific for blunt
diaphragmatic rupture in our study. However, they were isolated poor
predictors of blunt diaphragmatic rupture and were always associated with
other obvious signs—such as intrathoracic herniation of abdominal organs
and either diaphragmatic discontinuity or segmental nonrecognition of the
diaphragm—that were good predictors of blunt diaphragmatic rupture. The
dependent viscera sign has a reported sensitivity of 90%
[13] but had a sensitivity of
56.2% for patients with blunt diaphragmatic rupture in our study, all of whom
also had intrathoracic herniation of abdominal organs. Intrathoracic
herniation of abdominal organs was found in 60% of patients in the study of
Bergin et al. [13], versus 75%
in our study. This sign is a prerequisite for observing the collar sign, which
may be more visible with orthogonal reformatting
[19]. Among the other poor
predictors of blunt diaphragmatic rupture, diaphragmatic laceration by a
fractured rib, described by Larici et al.
[18], had 0% sensitivity for
the diagnosis of blunt diaphragmatic rupture in our series. Also, unlike
Larici et al., we found contrast medium extravasation at the level of the
diaphragm to be insensitive (0%). This sign may be responsible for a
false-positive diagnosis in the presence of a hemorrhaging liver or spleen
injuries with spread of contrast medium to the diaphragmatic concavity. On the
other hand, a hypoattenuated hemidiaphragm, found in one patient in
association with segmental nonrecognition and thickening of the diaphragm,
indicated devascularization of the diaphragmatic muscle. To our knowledge,
this sign has not previously been described.
Six of the 11 evaluated signs were strong predictors of blunt diaphragmatic
rupture. An association between hemothorax and hemoperitoneum is frequently
observed in thoracoabdominal contusions and, like blunt diaphragmatic rupture,
may reflect the severity of trauma. Reported sensitivity in the series of
Murray et al. [8] was 18%,
compared with 50% in our series, with a specificity of 95%. Pitfalls have to
be avoided in the interpretation of the other strong predictors of blunt
diaphragmatic rupture. As an illustration, the only patient with a
false-positive sign of abdominal organ elevation had right-sided diaphragmatic
relaxation. The other patients with false-positive signs of diaphragmatic
discontinuity and intrathoracic herniation of abdominal organs included those
with diaphragmatic defects, which are present in up to 11% of the healthy
population and are known to increase with aging
[20].
We included in our control group 65 patients who did not undergo surgical
exploration; all had 1 year of negative follow-up findings by different
imaging techniques. A short follow-up may be considered a relative limitation,
because herniation can occur after 1 year in a minority of patients
[6]. Absence of
gastrointestinal opacification and the use of 5- to 10-mm collimating axial
slices that have limited orthogonal reformatting capability were other
speculative limitations of our study. Orthogonal reformatting with
single-detector scanners has been studied elsewhere, with variable
significance [10,
11]. The use of scans with 1-
to 3-mm collimation and with the fast orthogonal reformatting allowed by MDCT
scanners may improve the diagnosis of blunt diaphragmatic rupture, especially
for small defects. However, this possibility will require further assessment,
because the recognition of abnormalities in the axial plane first lead
performance of orthogonal imaging. Most initial interpretations were performed
using the CT display, whereas the current study used printed films. Although
the diagnostic sensitivity of the reviewers for blunt diaphragmatic rupture
could have been altered by the study design, bias was avoided by giving all
reviewers the same material.
In summary, the presence of blunt diaphragmatic rupture should be
considered in the presence of any of the reported signs, and a high index of
suspicion should be maintained until the diagnosis is ruled out or confirmed.
Among the analyzed CT signs in this study, six were good predictors of blunt
diaphragmatic rupture. Despite diaphragmatic thickening, focal defect and
segmental nonrecognition had a 100% cumulative sensitivity in the current
study; reviewers formulating the diagnosis before meticulously analyzing the
signs overlooked blunt diaphragmatic rupture at a rate similar to that
reported in the literature.
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Abstract
Introduction
