The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture

The objectives of our study were to describe a new CT sign of diaphragmatic injury, the “dangling diaphragm” sign, and assess its comparative utility relative to other signs in the diagnosis of diaphragmatic injury resulting from blunt trauma. CT scans of 16 blunt trauma patients (12 men and four women, mean age 36.6 years old) with surgically proven diaphragmatic injury and 32 blunt trauma patients (24 men and eight women; mean age 37.4 years old) without evidence of diaphragmatic injury at surgery were blindly reviewed by three board certified radiologists specializing in body imaging. Studies were evaluated for the presence of established signs of diaphragmatic injury, as well as the dangling diaphragm sign, in which the free edge of the torn hemidiaphragm curls inward from its normal course parallel to the body wall. The sensitivity and specificity of each sign were determined, as were the correlation between the signs and the interobserver agreement in evaluation of these findings. The radiologists’ overall impression as to whether rupture was present was also recorded. In select cases, coronal and/or sagittal reformatted images were available, and they were reviewed following evaluation of the original axial images. Any change in interpretation due to these images was noted. The sensitivity of the radiologists’ overall impression for detection of diaphragmatic injury was 77%, with 98% specificity. Individual signs of diaphragmatic injury had sensitivities ranging from 44% to 69%, with specificities of 98% to 100%. The dangling diaphragm sign had a sensitivity of 54% and a specificity of 98%, similar to the other signs. Multiple signs were present in most cases of diaphragmatic injury, and coronal and sagittal reformatted images had little impact. Diaphragmatic injury remains a challenging radiographic diagnosis. The dangling diaphragm is a conspicuous sign of diaphragmatic injury, and awareness of it may increase detection of diaphragmatic injury on CT studies.     

Helical CT of blunt diaphragmatic rupture

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.     

创伤性膈疝的影像学诊断

创伤性膈疝是胸腹结合部严重损伤的一种类型,常因胸腹部损伤症状的掩盖而误诊、漏诊,死亡率高。笔者搜集2000年3月～2008年4月间经外科手术证实且临床、影像资料完整的14例创伤性膈疝进行分析,现报告如下。     

Helical CT of diaphragmatic rupture caused by blunt trauma

OBJECTIVE: The purpose of this study was to determine the diagnostic sensitivity and specificity of helical CT with sagittal and coronal reformatted images in detecting diaphragmatic rupture after blunt trauma. MATERIALS AND METHODS: Chest and abdominal helical CT scans obtained in 41 patients with suspected diaphragmatic injury after major blunt trauma were reviewed by three observers who were unaware of surgical findings. Coronal and sagittal reformatted images were reviewed for each patient as well. Findings consistent with diaphragmatic injury, such as waistlike constriction of abdominal viscera (i.e., the "collar sign"), intrathoracic herniation of abdominal contents, and diaphragmatic discontinuity were recorded. Sensitivity and specificity of helical CT were calculated on the basis of surgical findings and clinical follow-up. RESULTS: Helical CT was performed preoperatively in 23 patients with diaphragmatic rupture (left, n = 17; right, n = 5; bilateral, n = 1). An additional 18 patients underwent helical CT to further evaluate suspicious findings seen on chest radiography at admission and were found to have an intact diaphragm. Sensitivity for detecting left-sided diaphragmatic rupture was 78% and specificity was 100%. Sensitivity for the detection of right-sided diaphragmatic rupture was 50% and specificity was 100%. The most common CT finding of diaphragmatic rupture was the collar sign, identified in 15 patients (sensitivity, 63%; specificity, 100%). Diaphragmatic discontinuity was seen in four patients. CONCLUSION: Helical CT, especially with the aid of reformatted images, is useful in the diagnosis of acute diaphragmatic rupture after blunt trauma. Helical CT can be used to detect 78% of left-sided and 50% of right-sided injuries.     

Sinus cut-off sign: a helpful sign in the CT diagnosis of diaphragmatic rupture associated with pleural effusion

The objective of our study was to describe the "sinus cut-off" sign at CT in the diagnosis of diaphragmatic rupture in patients with blunt abdominal trauma complicated with pleural effusion, and evaluate its utility in an experimental model. Between January 2004 and March 2005, we observed an unusual interruption of costophrenic sinus at CT in three patients with blunt abdominal trauma accompanied with pleural effusion. This observation prompted us to evaluate the utility of this sign in an experimental model. Laparotomically, we created 2 cm diapragmatic lacerations at each hemidiaphragm in two rabbits and pushed up the abdominal viscera with omentum through the defect. To simulate hemothorax, we also injected 5-10 mL of diluted contrast material into the pleural space. Using a dual-slice helical CT scanner, limited thoracoabdominal CT examination was performed before and after injection of intrapleural contrast material. The images were analyzed for the presence of CT signs for diaphragmatic injury. The left posterior costophrenic sulcus was interrupted in all of the three patients with left pleural effusion. While it was associated with other findings of diaphragmatic injury, the "sinus cut-off sign" was the sole finding in one patient. The sinus cut-off sign was observed on the CT scans of 100% of the rabbits with a left and right sided diaphragmatic rupture. The "sinus cut-off sign" is useful and can increase the CT detection of acute diaphragmatic injury associated with pleural effusion.     

创伤性膈肌破裂的早期诊断及治疗

目的 探讨创伤性膈肌破裂(traumatic diaphragmatic rupture,TDR)的早期诊断及治疗.方法 回顾分析了2003年6月～2007年1月创伤中心收治的26例TDR病例资料.本组平均ISS为(20.5±9.2)分;左侧TDR 24例(92.3%);右侧TDR 2例(7.7%);21例伴有胸、腹腔脏器损伤,20例伴膈疝形成;23例术前有影像学检查(胸腹部X片、CT)结果.26例均行急诊手术治疗.结果 TDR患者男性明显多于女性(P＜0.01);左侧TDR发生率高于右侧(P＜0.01);影像学检查对TDR诊断符合率为85.0%.TDR术前诊断率88.5%.26例全部治愈,无并发症发生.结论 对严重胸腹伤患者,应重视TDR发生,早期诊断依据对本病的警惕,结合病史、体格检查及影像学结果进行综合分析;在保证病人生命安全的情况下,适时掌握TDR的手术时机,正确选择处理顺序、手术入路和修补方式,能提高救治成功率和降低并发症发生率.     

CT diagnosis of traumatic pericardium rupture

A case of traumatic rupture of the pericardium secondary to a motor vehicle accident is presented. Diagnosis of this condition was made prior to surgery by CT.     

7例外伤性支气管断裂的CT诊断

回顾性分析7例外伤性支气管断裂的cT表现,探讨外伤性支气管断裂CT检查的临床诊断价值。     

创伤性膈肌破裂的表现及诊治中值得注意的问题

目的探讨创伤性膈肌破裂(TDR)的表现及诊治中值得注意问题。方法笔者回顾性分析1980年1月~2015年1月收治TDR 54例的临床资料,男性43例,女性11例;年龄7~68岁,平均(36±16.2)岁。左侧膈肌破裂48例,右侧6例。开放性、闭合性膈肌破裂膈疝发生率各为10.0%(1/10)和90.9%(40/44)(P0.01)。结果患者伤后或入院24h内未能确诊31例占57.4%,院内、外延误诊断率各为14.8(8/54)%和42.6%(23/54)(P0.01);X线、CT、B超对膈疝的检出率各为51.4%(19/37)、87.5%(28/32)和56.3%(9/16),其中23例经2种以上检查手段确诊,CT组与X线、B超组比较差异均有统计学意义(P0.05);41例膈疝术中证实均难自行还纳,其中29.3%与胸腔形成粘连,9例因疝入脏器破裂或绞窄、坏死行手术修补或切除。本组治愈51例(94.4%),因创伤性休克、重型颅脑损伤合并多器官功能衰竭死亡3例(5.6%),其ISS平均值为42.4分。结论伤后出现胸腹双腔症/症候群和膈疝影像学特征是诊断TDR的主要依据,早期诊断、合理选择手术方法、积极处理合并伤是临床关注的重点。     

钝性伤致膈肌破裂的治疗

总结29例钝性伤致膈肌破裂的外科治疗体会。认真、仔细观察X线检查征象,结合上消化道造影是早期诊断的关键,一经确诊应立即手术治疗。     

多层螺旋CT在创伤性膈疝诊断中的应用

目的 探讨多层螺旋CT多平面重组图像在创伤性膈疝诊断中的应用.方法 回顾性分析10例经手术证实的创伤性膈疝的多层螺旋CT表现,重点分析多平面重组图像特点.10例患者术前均行胸部正位片及多层螺旋CT检查.结果 8例X线有阳性发现,提示创伤性膈疝;而10例患者经多层螺旋CT多平面重组图像后矢状位、冠状位清晰可见膈肌连续性中断,并清晰显示裂口的位置、裂口的大小及疝入胸腔的内容物.全部病例均经手术治疗并痊愈.结论 多层螺旋CT多平面重组图像在创伤性膈疝中有重要价值,确诊后均应及时手术治疗.     

CT diagnosis of traumatic abdominal aortic rupture

Blunt injury to the abdominal aorta has been previously reported. Due to the severity of the lesion, radiologic studies other than aortography are rarely undertaken prior to emergency surgery. We report a case in which CT initially demonstrated an angiographically and surgically proven rupture of the infrarenal abdominal aorta due to blunt trauma.     

创伤性膈肌破裂的诊治

回顾性分析 4 3例创伤性膈肌损伤的诊治经验。认为膈肌破裂症状无特异性 ,对外伤病人应根据外伤史、伤口部位及伤道情况选择适当的辅助检查 ,及时诊断、及时手术治疗 ,在胸、腹损伤手术中应注意探查膈肌 ,避免遗漏     

34例创伤性膈肌破裂的早期诊断和外科治疗

目的总结创伤性膈肌破裂（TDR）的早期诊断和外科治疗的临床经验。方法回顾性分析1995年1月-2006年12月我院收治的34例创伤性膈肌破裂（TDR）患者的临床资料，对其发病原因、合并伤、诊断及手术途径分别进行分析。结果34例术前确诊14例，治愈32例，死亡2例。结论早期诊断和积极治疗是救治创伤性膈肌破裂的关键。     

34例创伤性膈肌破裂的早期诊断和外科治疗

目的 总结创伤性膈肌破裂(TDR)的早期诊断和外科治疗的临床经验.方法 回顾性分析1995年1月～2006年12月我院收治的34例创伤性膈肌破裂(TDR)患者的临床资料,对其发病原因、合并伤、诊断及手术途径分别进行分析.结果 34例术前确诊14例,治愈32例,死亡2例.结论 早期诊断和积极治疗是救治创伤性膈肌破裂的关键.     

MR imaging of traumatic diaphragmatic rupture

The diagnosis of traumatic rupture of the diaphragm may remain elusive despite a variety of imaging options including CT and sonography. Direct sagittal and coronal magnetic resonance images provided a definitive diagnosis of left diaphragmatic rupture with herniation of colon into the thorax.     

闭合性腹膜内型膀胱破裂的CT诊断

目的　确定闭合性腹膜内型膀胱破裂的CT诊断价值。方法　对 9例闭合性腹膜内型膀胱破裂的CT资料和临床处理进行回顾性分析。结果　所有 9例腹膜内型膀胱破裂 ,CT均明确诊断。CT显示腹膜腔内低密度液体积聚 9例 ,其CT值比血液低 ,主要分布在膀胱侧隐窝、盆腔陷凹、结肠旁沟、肝脾周围和肠袢内。膀胱壁局部缺损 3例 ,泪滴状变形 2例 ;其他支持膀胱破裂的CT征象包括 :膀胱充盈不良 8例 ,膀胱壁挫伤 4例 ,膀胱内血凝块 6例。结论　在创伤情况下 ,腹膜腔内出现CT值比血液小的低密度液体积聚 ,强烈提示尿外渗 ,根据尿外渗的分布范围 ,CT还可以区别腹膜内和腹膜外型膀胱破裂。CT有时还可以观察到膀胱破裂的准确位置 ,有利于手术修补     

CT diagnosis of traumatic rupture of the cisterna chyli

The CT findings are presented in a patient with chyloperitoneum and chyloretroperitoneum following blunt trauma to the cysterna chyli. The simultaneous demonstration of both intraperitoneal and extraperitoneal water density fluid appears to be specific for this injury.