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Computed tomography of blunt and penetrating diaphragmatic injury: sensitivity and inter-observer agreement of CT Signs

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Abstract

Diaphragmatic injury is an uncommon but clinically important entity in the setting of trauma. Computed tomography (CT) is widely used to evaluate hemodynamically stable trauma patients. While prior studies have identified CT signs of diaphragm injury in blunt or penetrating trauma, no study has directly compared signs across these two types of injuries. We identified patients with surgically proven diaphragm injuries who underwent CT at presentation. Three reviewers examined each for 12 signs of diaphragm injury, as well as for an overall impression of diaphragm injury. We reviewed a total of 84 patients (37 % blunt trauma, 63 % penetrating). The initial interpreting radiologists discovered 77 % of blunt and 47 % of penetrating injuries (p = 0.01). We found that the majority of signs of diaphragmatic injury were split between those common in blunt trauma and those common in penetrating trauma, with minimal overlap. The presence of at least one blunt injury sign has 90 % sensitivity for diaphragm injury in blunt trauma; the presence of a wound tract traversing the diaphragm has 92 % sensitivity in penetrating trauma. Inter-observer reliability of these signs is also high (κ > 0.65). Penetrating diaphragm injuries present a different spectrum of imaging findings from those in blunt trauma and are underdiagnosed at CT; looking for a wound tract traversing the diaphragm is highly sensitive for diaphragm injury in these cases. Signs of organ or diaphragm fragment displacement are sensitive for blunt diaphragm injuries, consistent with these injuries being caused by increased intra-abdominal pressure.

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Conflict of Interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Mallinckrodt Institute of Radiology, Washington University School of Medicine, Barnes-Jewish Hospital, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO, 63110, USA

    Mark M. Hammer, Vincent M. Mellnick, Kristopher W. Cummings, Sanjeev Bhalla & Constantine A. Raptis

  2. New York University School of Medicine, New York, NY, USA

    Eric Flagg

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  1. Mark M. Hammer
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  2. Eric Flagg
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  3. Vincent M. Mellnick
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  4. Kristopher W. Cummings
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  5. Sanjeev Bhalla
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  6. Constantine A. Raptis
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Corresponding author

Correspondence to Mark M. Hammer.

Additional information

Mark M. Hammer and Eric Flagg contributed equally to the work.

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Supplementary Figure 1

Additional examples of signs of diaphragmatic injury. a 33-year-old male in a motor vehicle collision with surgically proven left-sided diaphragm injury; this case demonstrates the dangling diaphragm sign (arrowhead), intra-thoracic herniation of the stomach, the collar sign (arrow), dependent viscera, and elevated abdominal organs (coronal reformat). b 25-year-old man in a motor vehicle collision with surgically proven bilateral diaphragm injury. This case demonstrates the band sign (arrows), intra-thoracic and dependent viscera, and elevated abdominal organs. c 53-year-old woman in a motor vehicle collision with surgically proven left-sided diaphragm injury; this case demonstrates diaphragmatic discontinuity and focal diaphragm thickening (arrow). d 19-year-old man in a motor vehicle collision with surgically proven left diaphragm injury. Transverse CT image demonstrates diffuse diaphragmatic thickening (arrows) as well as diaphragmatic discontinuity and intra-thoracic herniation of small bowel (PPTX 1,585 kb)

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Hammer, M.M., Flagg, E., Mellnick, V.M. et al. Computed tomography of blunt and penetrating diaphragmatic injury: sensitivity and inter-observer agreement of CT Signs. Emerg Radiol 21, 143–149 (2014). https://doi.org/10.1007/s10140-013-1166-0

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  • DOI: https://doi.org/10.1007/s10140-013-1166-0

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