World Journal of Radiology. Blunt diaphragmatic lesions: Imaging findings and pitfalls

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1 W J R World Journl of Rdiology Submit Mnuscript: Help Desk: DOI: /wjr.v8.i World J Rdiol 2016 October 28; 8(10): ISSN (online) 2016 ishideng Publishing Group Inc. ll rights reserved. MINIREVIEWS lunt diphrgmtic lesions: Imging findings nd pitflls Mtteo ontti, Fbio Lombrdo, Norberto Vezzli, Giuli Zmboni, Gimpietro ontti Mtteo ontti, Norberto Vezzli, Gimpietro ontti, Deprtment of Rdiology, olzno Centrl Hospitl, olzno, Itly Fbio Lombrdo, Giuli Zmboni, Deprtment of Rdiology, University of Veron, Veron, Itly uthor contributions: ontti M nd Lombrdo F wrote the pper; ll the uthors collborted in dt collection nd pper review. Conflict-of-interest sttement: There is no conflict of interest ssocited with ny of the senior uthor or other co-uthors contributed their efforts in this mnuscript. Open-ccess: This rticle is n open-ccess rticle which ws selected by n in-house editor nd fully peer-reviewed by externl reviewers. It is distributed in ccordnce with the Cretive Commons ttribution Non Commercil (CC Y-NC 4.0) license, which permits others to distribute, remix, dpt, build upon this work non-commercilly, nd license their derivtive works on different terms, provided the originl work is properly cited nd the use is non-commercil. See: licenses/by-nc/4.0/ Mnuscript source: Invited mnuscript Correspondence to: Mtteo ontti, MD, Deprtment of Rdiology, olzno Centrl Hospitl, 5 oehler St., olzno, Itly. mtteobontti@hotmil.com Telephone: Fx: Received: Mrch 30, 2016 Peer-review strted: Mrch 31, 2016 First decision: My 17, 2016 Revised: My 31, 2016 ccepted: ugust 27, 2016 rticle in press: ugust 29, 2016 Published online: October 28, 2016 trum ptients, but they should be promptly recognized s delyed dignosis increses morbidity nd mortlity. It is well known tht DL re often overlooked t initil imging, minly becuse of distrcting injuries to other orgns. Sonogrphy my directly depict DL only in minor number of cses. Chest X-ry hs low sensitivity in detecting DL nd lesions cn be relibly suspected only in cse of intr-thorcic hernition of bdominl viscer. Thnks to its wide vilbility, timeeffectiveness nd sptil resolution, multi-detector computed tomogrphy (CT) is the imging modlity of choice for dignosing DL; severl direct nd indirect CT signs re ssocited with DL. Given its high tissue contrst resolution, mgnetic resonnce imging cn ccurtely depict DL, but its use in n emergency setting is limited becuse of longer cquisition times nd need for ptient s collbortion. Key words: Diphrgm; lunt injury; Trum; Imging; Computed tomogrphy The uthor(s) Published by ishideng Publishing Group Inc. ll rights reserved. Core tip: lunt diphrgmtic lesions (DL) re uncommon, but they should be promptly recognized s delyed dignosis increses morbidity nd mortlity. We herein discuss multi-modlity imging findings in DL nd possible pitflls in order to help the rdiologist in this sometimes-difficult dignosis. ontti M, Lombrdo F, Vezzli N, Zmboni G, ontti G. lunt diphrgmtic lesions: Imging findings nd pitflls. World J Rdiol 2016; 8(10): vilble from: URL: wjgnet.com/ /full/v8/i10/819.htm DOI: org/ /wjr.v8.i bstrct lunt diphrgmtic lesions (DL) re uncommon in INTRODUCTION lunt diphrgmtic lesions (DL) represent reltively 819 October 28, 2016 Volume 8 Issue 10

2 Figure 1 Physiologicl wekness points of the diphrgm. This volumerendering reconstruction shows the most common sites of diphrgm rupture, which re locted in the postero-lterl re (red circles) nd in the nteromedil re (green circles) of ech hemidiphrgm. lunt diphrgmtic lesions usully show rdil course (dotted lines). uncommon event, with estimted prevlence of 0.2%-7% in ptients dmitted to n Emergency Deprtment (ED) becuse of blunt trum [1-3]. lthough DL re rrely lifethretening by themselves in the cute phse, ptients suffering from DL show high mortlity rtes, rnging from 5% to 50%, becuse of ssocited bdominl, thorcic nd brin injuries [4-6]. Every diphrgmtic lesion should undergo surgicl reprtion s soon s possible in order to prevent further complictions, like intestinl obstruction or respirtory distress, nd to improve ptient outcome [7]. Despite the need for n erly dignosis, DL remin undignosed t initil imging in 7%-66% of the cses [8-10], minly becuse of the presence of distrcting injuries. The im of our work is to review imging findings nd possible pitflls in ptients with DL in order to improve correct dignosis rtes. ntomicl bckground nd trumtic mechnisms The diphrgm represents the ntomicl lndmrk between thorcic nd bdominl cvities nd serves s the min muscle for respirtion. ilterlly, the diphrgm is composed by three min musculr groups, originting from the lumbr vertebre, from the inferior border of the ribs nd from the sternum, tht converge into thin strong centrl tendinous sheet. ilterlly, in the sites where these musculr groups converge, the soclled lumbo-costl tringles nd sterno-costl tringles, musculr fibers re replced by thin reolr tissue, which constitutes physiologicl wekness point. Moreover, the posterolterl re of ech hemidiphrgm represents wekness point lso being the site where, during the 8 th gesttionl week, the pleuroperitonel membrnes join with the septum trsversum to close the pleuroperitonel hitus. DL re usully the consequence of high-energy blunt bdominl trums tht determine sudden increse in bdominl pressure [11], nd motor-vehicle collisions represent the most common mechnism of injury. bdominl pressure is trnsmitted to the diphrgm tht my crck in its physiologicl wekness points. Less common trumtic mechnisms re represented by highenergy lterl impcts tht cuse chest wll distortion nd subsequent diphrgm shering, nd by direct lcertions from frctured ribs. In the mjority of cses DL show rdil course, strting from the postero-lterl res of the diphrgm nd extending towrds the centrl ones (Figure 1) for t lest 10 cm [12]. The brekge flps usully remin close to ech other during the erly post-trumtic stges, but fterwrds they tend to move wy becuse of the difference between the positive intr-bdominl pressure nd the negtive pleurl spce one tht cuses intr-thorcic viscerl hernition. Left DL re significntly more frequent thn right ones (2:1-7:1 rtios), probbly becuse of the protective effect of the liver on the right hemidiphrgm nd of reltive wekness of the left hemidiphrgm itself. This difference might lso be the consequence of bis in ptient selection: Indeed, right DL remin undignosed t initil imging with significntly higher prevlence thn left ones [13]. Clinicl presenttion, dignosis nd tretment DL re often symptomtic in their cute phse, but rrely occur s isolted injuries, s other life-thretening lesions re ssocited in 50%-100% of cses. Splenic, heptic nd renl injuries re the most commonly ssocited bdominl lesions, wheres hemothorx, pneumothorx nd rib frctures re the most frequent thorcic ones. Intr-thorcic hernition of bdominl viscer represents ner-invrible consequence of DL, which my mnifest from few seconds to mny months fter trum. Intr-thorcic viscer hernition lso represents the premise for further complictions like intestinl incrcertion, strngultion nd occlusion, but lso respirtory insufficiency. eing clinicl dignosis of DL virtully impossible, imging plys centrl role for this gol. However, it is well known tht DL often remins unrecognized t initil imging, minly becuse of the presence of distrcting injuries, nd my become mnifest only lter becuse of complictions [5,14]. Delyed presenttion is ssocited with incresed morbidity nd mortlity [15,16]. Tretment of DL implictes lprotomy in the mjority of the cses, wheres lproscopy nd thorcotomy re less frequently performed [6]. Lprotomy is preferred in hemodynmiclly unstble ptients nd in ptients with ssocited intr-bdominl injuries [11]. First of ll the surgeon must crefully exmine both hemidiphrgms nd, in cse of intr-thorcic viscer hernition, he must reposition the hernited viscer into the bdominl cvity. The diphrgmtic rupture cn then be repired by mens of interrupted or continuous non-bsorbble sutures nd, finlly, chest tube should be plced in the ffected pleurl cvity. In cse of lrge 820 October 28, 2016 Volume 8 Issue 10

3 Figure 2 Chest X-ry findings in blunt diphrgmtic lesions. This nteroposterior chest X-ry shows viscer hernition in the thorcic cvity (circle) in ssocition with costophrenic sulcus oblitertion nd distorted diphrgmtic profile. Figure 3 Sonogrphic findings in blunt diphrgmtic lesions. This trnsversl ultrsound scn directly shows the ruptured right hemidiphrgm (rrows) surrounded by thickened diphrgm edges (rrowheds). good coustic window is present due to lrge pleurl effusion (). diphrgmtic rupture prosthetic ptch cn be used for closing the gp. IMGING OF DL Chest X-ry Chest X-ry (CXR) is performed directly in the shock room in the mjority of ptients dmitted to the ED becuse of blunt trum [17]. Given the cute setting nd the generl conditions of the ptients, CXR is usully performed by mens of single ntero-posterior projection with the ptient lying supine. CXR hs n unstisfctory ccurcy in detecting DL; indeed, it my pper norml or it my show only nonspecific chnges in 20%-50% of the ptients ffected by diphrgmtic rupture [18-21]. The only direct sign of DL t chest rdiogrm is represented by the visuliztion of hernited bowel loops into the thorcic cvity (Figure 2). owel loops hernition my be pprecited directly or indirectly, becuse of nsogstric tube pex disloction. Some indirect signs might lso be present, suggesting the possibility of DL, but their sensitivity is extremely vrible nd their specificity is usully unstisfctory. For exmple, hemidiphrgm elevtion is strongly ssocited with DL nd previously published studies reported dignostic ccurcies of bout 60% [9,22], but its specificity is extremely low, being often present in ptients suffering from thorcic trum. Other low-specificity signs ssocited with DL re costophrenic sulcus oblitertion nd distorted diphrgmtic profile. In ny cse, the comprison with pre-trum scns, whenever vilble, my increse the dignostic performnce by highlighting eventul post-trumtic chnges. Ultrsound Sonogrphy, usully in the form of fst scn, represents the first line imging modlity performed in the mjority of blunt trum ptients dmitted to the ED. t sonogrphy the diphrgm cn be recognized s curved hyperechoic structure, with homogeneous thickness, dividing the bdominl cvity from the thorcic one. If good thorcic coustic window is present (i.e., in cse of lrge pleurl effusions), in ptients with lrge diphrgmtic ruptures ultrsound my directly depict the lesion s focl interruption of the hyperechoic diphrgmtic line (Figure 3). Floting diphrgm edges nd intr-thorcic viscerl hernition my lso be observed [23-25]. On the other hnd, smll diphrgmtic lesions cn be hrdly identified nd the interprettion of diphrgmtic thickenings remins extremely debted. esides the direct visuliztion of the rupture, some indirect sonogrphic signs hve lso been ssocited with DL. The impossibility of visulizing one or more hypochondric orgns or the hert without ny prticulr technicl fctor ble to explin it (the so-clled Rip s bsent orgn sign [24] ) in ptient dmitted to the ED becuse of severe blunt bdominl trum, s well s the hypomobility of one hemidiphrgm in comprison to the other, should rise the suspicion of DL. In these cses, further exmintions, nd in prticulr the performnce of contrst-enhnced multidetector computed tomogrphy (MDCT) scn, re mndtory. MDCT MDCT hs nowdys become the imging modlity of choice in trum ptients nd lso for dignosing DL. Indeed, thnks to the technologicl developments tht led to the introduction of multidetector scnners in the clinicl prctice, CT offers high ccurcy (61%-87% sensitivity nd 72%-100% specificity) in dignosing DL [26]. CT scns should be cquired with the ptient lying supine on the tble, with the hnds over its hed whenever possible; otherwise, the rms should be bent over pillow on his bdomen in order to reduce bem hrdening rtifcts. The cquisition should be s fst s possible in order to prevent motion rtifcts [27]. Contrst 821 October 28, 2016 Volume 8 Issue 10

4 Figure 4 Computed tomogrphy findings in blunt diphrgmtic lesions - segmentl defect. These 3 mm thick xil () nd coronl () multiplnr reconstructions show segmentl diphrgmtic defect (rrows) surrounded by diphrgmtic thickening tht indictes muscle retrction (rrowheds). Figure 5 Computed tomogrphy findings in blunt diphrgmtic lesions - diphrgm non-visuliztion. These 3 mm thick xil () nd coronl () multiplnr reconstructions show lck of diphrgm visuliztion, without the cler demonstrtion of ter (rrows), ssocited with intr-thorcic viscer hernition (). mteril dministrtion increses the conspicuity between different ntomicl structures nd, therefore, it is useful in order to better delimitte the diphrgm. Moreover, the evlution of multiplnr reconstructions on sgittl nd coronl plnes increses CT ccurcy in DL detection [28,29]. CT often llows to directly depict diphrgmtic lesions s segmentl defects; other direct signs of DI re diphrgm non-visuliztion, dngling diphrgm sign nd diphrgm thickening. Mny different indirect signs hve lso been ssocited with DL, i.e., intrthorcic viscer hernition, dependent viscer sign, collr sign nd hump nd bnd sign. segmentl diphrgmtic defect (Figure 4) represents the most commonly encountered sign of DL, with sensitivity vlues up to 95.7% in the most recent Literture [26,30]. The defect cn be better pprecited on multiplnr reconstructions performed perpendiculr to the ter thn on xil imges [31]. In the mjority of the cses, the defect is delimited by slightly thickened diphrgmtic edges, s consequence of edem, intrmusculr hemtom nd muscle retrction. ttention must be pid to physiologicl diphrgmtic defects, which my be observed in up to 11% of helthy popultion, with prevlence tht increses with ge [32] : In these cses, no edge thickening is observed. In cse of lrge diphrgmtic lesions, prtil or complete diphrgm non-visuliztion (Figure 5) represents reltively frequent event nd it is lmost lwys ssocited with intr-thorcic viscer hernition. The retrcted diphrgm my be sometimes recognized t its bone insertion. The sensitivity of this sign is not s high s tht of simple diphrgmtic defect, but its specificity pproches 100%. Intr-thorcic viscer hernition (Figure 6) represents the direct consequence of the difference between intr-bdominl nd intr-thorcic pressure, which brings the bdominl orgns to hernite in the thorcic cvity if lrge-enough diphrgmtic lesion is present. Viscer hernition is more common on the left thn on the right side, becuse of the lck of the protective effect of the liver. Hernition probbility increses prllel to ter extension. Intrpericrdil hernition represents rre but potentilly ftl event [19]. Diphrgm thickening (Figure 7) is usully present in ssocition with other signs of diphrgm rupture, but it my lso be the only finding of smll DL. In highenergy blunt trums, diphrgm thickness should be lwys ccurtely compred with the contrlterl side in order to rule out lesion. Diphrgm thickening my be the consequence of musculr edem or 822 October 28, 2016 Volume 8 Issue 10

5 Figure 6 Computed tomogrphy findings in blunt diphrgmtic lesions - intrthorcic viscer hernition. These 3 mm thick coronl () nd sgittl () multiplnr reconstructions show intrthorcic hernition of bdominl orgns nd ft (). This finding is often ssocited with diphrgm non-visuliztion or with lrge diphrgmtic defects. Figure 7 Computed tomogrphy findings in blunt diphrgmtic lesions - diphrgm thickening. These 3 mm thick coronl () nd sgittl () multiplnr reconstructions show n bnormlly thickened left hemidiphrgm (rrows), highly suspicious for blunt diphrgmtic lesions in ptients with multiple ribs frctures nd pneumothorx. Figure 8 Computed tomogrphy findings in blunt diphrgmtic lesions - dngling diphrgm sign. This 3 mm thick multiplnr xil reconstruction shows the free edges of torn diphrgm s comm-shped structures (rrows) which curl inwrd, towrd the center of the bdomen. This ltertion represents the so-clled dngling diphrgm sign. hemtom, but it my lso be the indictor of stillclosed diphrgmtic ter; therefore, this finding should be lwys highlighted in the rdiologicl report nd, in cse of ptients without ny other indiction for surgicl explortion, it must be strictly followed-up by mens of CT. nywy, some vribility in diphrgmtic thickness my be physiologicl [12]. The dngling diphrgm sign (Figure 8) ws first described by Desser et l [33] in 2010 s the visuliztion of the free edges of the torn diphrgm s commshped structures, which curl inwrd, towrd the center of the bdomen. It is usully ssocited with segmentl diphrgmtic defect nd diphrgm thickening. The dngling diphrgm sign my be observed in only bout 50% of the ptients with DL, but its specificity reches 98% [26,30,33]. The dependent viscer sign [34] (Figure 9) (lso referred to s sinus cutoff sign [35] ) ws first described by ergin et l [34] in 2001 nd is represented by n nomlous contct between bdominl viscer nd posterior chest wll, without the physiologicl lung prenchym interposition. It is the consequence of the loss of the diphrgmtic support to the bdominl orgns tht, therefore, in the supine position tend to lie dorslly. It ws prticulrly useful for DL detection in the premultiplnr reconstructions er. The collr sign (lso referred to s hourglss sign) (Figure 10) is represented by wist-like constriction 823 October 28, 2016 Volume 8 Issue 10

6 Figure 9 Computed tomogrphy findings in blunt diphrgmtic lesions - dependent viscer sign. These 3 mm thick multiplnr xil () nd coronl () reconstructions show the spleen (rrows) nd the stomch () lying on the posterior chest wll, without lung prenchym interposition. This ltertion represents the so-clled dependent viscer sign. Figure 10 Computed tomogrphy findings in blunt diphrgmtic lesions - collr sign. These 3 mm thick multiplnr coronl reconstructions (2 different ptients, nd ) show intrthorcic hernition of the stomch (, ) nd of the right colic flexure (, ). In both cses the hernited mteril shows hourglss shpe s consequence of the compression exerted on it by the ruptured diphrgm edges (rrows). of the hernited viscer t the point of diphrgmtic discontinuity nd is typiclly observed in cse of left diphrgmtic lesions with gstric hernition. The hump nd bnd sign (Figure 11) is similr to the collr sign nd refers to the shpe of the hernited liver in cse of right DL. The hump shpe is due to the squeezing of the hernited liver bove the diphrgmtic defect, wheres the hypottenuting bnd is thought to be the consequence of locl liver prenchym hypoperfusion becuse of diphrgmtic compression. It is best pprecited on sgittl nd coronl reconstructions. The rdiologist must py prticulr ttention to the bove-mentioned signs in ptients with prenchyml orgns lesions, rib frctures, pleurl effusion, hemothorx or hemoperitoneum. Mgnetic resonnce imging Mgnetic resonnce imging (MRI) wrrnts higher tissue contrst resolution thn CT nd enbles to clerly depict the diphrgm (Figure 12), but its use in n emergency setting is limited by the longer cquisition times nd by the need for ptient collbortion. Moreover, the originl dvntge of MRI in comprison with CT in dignosing DL, i.e., its multiplnrity, hs been overwhelmed by the development of multidetector CT scnners. Therefore, nowdys MRI should be considered second level investigtion reserved to hemodynmiclly stble ptients with inconclusive findings t CT [36]. In order to better evlute the hemidiphrgms, MRI sequences should be cquired using crdic nd respirtory gting. The exmintion cn be simply bsed on spin-echo T1-weighted sequences, cquired on the xil, sgittl nd coronl plnes, in which the norml diphrgm ppers s continuous hypointense bnd surrounded by hyperintense bdominl nd subpleurl ft [37]. In this setting, diphrgmtic discontinuities s well s the other findings described for CT my be ccurtely recognized [38,39]. Grdient-echo T1- weighted sequences represent n lterntive to SE ones becuse of fster cquisition times, but chemicl shift rtifcts my limit their vlue. PITFLLS IN DL EVLUTION Flse negtive cses Slight ltertions, like slight diphrgmtic thickenings (Figure 13) or smll diphrgmtic defects, my often remin undignosed t initil imging, especilly if mjor 824 October 28, 2016 Volume 8 Issue 10

7 Figure 11 Computed tomogrphy findings in blunt diphrgmtic lesions - hump nd bnd sign. These 3 mm thick multiplnr xil () nd coronl () reconstructions show hypodense bnd tht crosses the liver prenchym in the site where it crosses the ruptured diphrgm (rrows), wheres the liver dome expnds bove it. This ltertion represents the so-clled hump nd bnd sign (). Figure 12 Mgnetic resonnce imging pperrnce of the diphrgm. This TSE T2-weighted sgittl imge shows the left hemidiphrgm s n uniformly thin intermedite signl intensity bnd (rrows) between lung prenchym nd intr-bdominl ft. 2 yr distrcting injuries re present, nd my mnifest only lter becuse of complictions. In the mtter of fcts, the presence of severe thorco-bdominl injuries should point the rdiologist s ttention to the diphrgm. DL dignosis my be more difficult in ptients receiving mechnicl ventiltion, in prticulr if positive pressures re dopted [40]. Indeed, mechnicl ventiltion reduces the difference between intr-bdominl nd intr-thorcic pressure, preventing bdominl viscer hernition (Figure 14) nd reducing lesion conspicuity. Flse positive cses Eventrtion (Figure 15) my involve n entire hemidiphrgm or only prt of it. In both cses muscle continuity must be clerly recognizble nd no bnorml diphrgmtic thickenings must be observed; on the other hnd, in cse of eventrtion the involved diphrgm is usully uniformly thinned. Congenitl hernis (Figure 16) re usully locted in the sme res where trumtic lesions occur nd, therefore, the differentil dignosis my be prticulrly chllenging. However, congenitl hernis re usully not ssocited with diphrgm thickening. Figure 13 Flse negtive cse of blunt diphrgmtic lesions. Three millimeters thick xil CT imges of the sme ptient, cquired fter precipittion trum () nd two yers lter (). Thickening of the ntero-medil prt of the left hemidiphrgm (, rrows) ws overlooked t the first CT scn, performed fter precipittion trum. Two yers lter, CT scn performed becuse of epigstric pin showed intr-thorcic viscer hernition (, ) s consequence of diphrgmtic rupture. CT: Computed tomogrphy. CONCLUSION In the er of multidetector CT nd of high qulity multiplnr reconstructions, the dignosis of DL should be no more overlooked by rdiologists working in n emergency setting. pproprite knowledge of the common nd less common signs of DL nd creful evlution of the diphrgm in ptients with blunt trum should enble timely nd ccurte dignosis. 825 October 28, 2016 Volume 8 Issue 10

8 C Intubted PP ventilted Estubted Figure 14 Effects of mechnicl ventiltion on blunt diphrgmtic lesions. The ntero-posterior chest X-ry, performed immeditely fter intubtion nd left pneumothorx dringe () in ptient dmitted to the ED becuse of severe motorbike ccident, showed double left diphrgmtic profile (circle), suspicious for DI. The finding ws not confirmed t the subsequent CT, performed fter the beginning of positive-pressure ventiltion, nd lso the CXR performed 2 d lter, fter pleurl dringe removl () did not show ny diphrgm ltertion. Three dys lter, fter estubtion, the ptient suffered respirtory insufficiency nd left pleurl dringe ws replced in the suspicion of relpsing pneumothorx; subsequent CXR (C) clerly demonstrted the presence of DI with intr-thorcic gstric hernition (circle). DI: lunt diphrgmtic lesions; CXR: Chest X-ry; CT: Computed tomogrphy; ED: Emergency Deprtment. Figure 15 Diphrgm eventrtion. nd : Eventrtion my mimick blunt diphrgmtic lesions. In cse of eventrtion diphrgm continuity (rrows) must lwys be recongnizble nd no brupt thickness chnges should be observed. Figure 16 Congenitl diphrgmtic herni. CXR () nd CT scn () of 3-mo-old ptient with congenitl left diphrgmtic herni (). The diphrgmtic edges re not thickened (rrows). CXR: Chest X-ry; CT: Computed tomogrphy. REFERENCES 1 Rodriguez-Morles G, Rodriguez, Shtney CH. cute rupture of the diphrgm in blunt trum: nlysis of 60 ptients. J Trum 1986; 26: [PMID: DOI: / ] 2 Sliker CW. Imging of diphrgm injuries. Rdiol Clin North m 2006; 44: , vii [PMID: DOI: / j.rcl ] 3 Hsee L, Wigg L, Civil I. Dignosis of blunt trumtic ruptured diphrgm: is it still difficult problem? NZ J Surg 2010; 80: [PMID: DOI: /j x] 4 Hciibrhimoglu G, Solk O, Olcmen, edirhn M, Solmzer N, Gurses. Mngement of trumtic diphrgmtic rupture. Surg Tody 2004; 34: [PMID: DOI: / s ] 826 October 28, 2016 Volume 8 Issue 10

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Prevlence nd Clinicl Import of Thorcic Injury Identified by Chest Computed Tomogrphy but Not Chest Rdiogrphy in lunt Trum: Multicenter Prospective Cohort Study. nn Emerg Med 2015; 66: [PMID: DOI: /j.nnemergmed ] 22 Gelmn R, Mirvis SE, Gens D. Diphrgmtic rupture due to blunt trum: sensitivity of plin chest rdiogrphs. JR m J Roentgenol 1991; 156: [PMID: DOI: / jr ] 23 livs M, rnnm L, Hwkins M, Lyon M, Srirm K. edside emergency ultrsonogrphic dignosis of diphrgmtic rupture in blunt bdominl trum. m J Emerg Med 2004; 22: [PMID: DOI: /j.jem ] 24 Gnghr R, Doshi D. FST scn in the dignosis of cute diphrgmtic rupture. m J Emerg Med 2010; 28: 387.e1-387.e3 [PMID: DOI: /j.jem ] 25 Kim HH, Shin YR, Kim KJ, Hwng SS, H HK, yun JY, Choi KH, Shinn KS. lunt trumtic rupture of the diphrgm: sonogrphic dignosis. J Ultrsound Med 1997; 16: [PMID: ] 26 Pnd, Kumr, Gmngtti S, Ptil, Kumr S, Gupt. Trumtic diphrgmtic injury: review of CT signs nd the difference between blunt nd penetrting injury. 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JR m J Roentgenol 1999; 173: [PMID: DOI: /jr ] 32 Cskey CI, Zerhouni E, Fishmn EK, Rhmouni D. ging of the diphrgm: CT study. Rdiology 1989; 171: [PMID: DOI: /rdiology ] 33 Desser TS, Edwrds, Hunt S, Rosenberg J, Purtill M, Jeffrey R. The dngling diphrgm sign: sensitivity nd comprison with existing CT signs of blunt trumtic diphrgmtic rupture. Emerg Rdiol 2010; 17: [PMID: DOI: / s ] 34 ergin D, Ennis R, Keogh C, Fenlon HM, Murry JG. The dependent viscer sign in CT dignosis of blunt trumtic diphrgmtic rupture. JR m J Roentgenol 2001; 177: [PMID: DOI: /jr ] 35 Ky SO, Krbulut N, Yuncu G, Sevinc S, Kiroğlu Y. Sinus cut-off sign: helpful sign in the CT dignosis of diphrgmtic rupture ssocited with pleurl effusion. Eur J Rdiol 2006; 59: [PMID: DOI: /j.ejrd ] 36 Eren S, Kntrci M, Okur. Imging of diphrgmtic rupture fter trum. Clin Rdiol 2006; 61: [PMID: DOI: /j.crd ] 37 Gierd DS, Curtin JJ, Erickson SJ, Prost RW, Strndt J, Goodmn LR. Diphrgmtic motion: fst grdient-reclled-echo MR imging in helthy subjects. Rdiology 1995; 194: [PMID: DOI: /rdiology ] 38 rbier F, Nicstro N, Finzzo M, Lo Csto, Runz G, rtolott TV, Midiri M. The role of MRI in trumtic rupture of the diphrgm. Our experience in three cses nd review of the literture. Rdiol Med 2003; 105: [PMID: ] 39 Shnmugnthn K, Mirvis SE, White CS, Pomerntz SM. MR 827 October 28, 2016 Volume 8 Issue 10

10 imging evlution of hemidiphrgms in cute blunt trum: experience with 16 ptients. JR m J Roentgenol 1996; 167: [PMID: DOI: /jr ] 40 Krmy-Jones R, Crter Y, Stern E. The impct of positive pressure ventiltion on the dignosis of trumtic diphrgmtic injury. m Surg 2002; 68: [PMID: ] P- Reviewer: Lovric Z, Slominy L S- Editor: Ji FF L- Editor: E- Editor: Li D 828 October 28, 2016 Volume 8 Issue 10

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