This document discusses the anatomy, physiology, imaging, and pathologies of the diaphragm. It describes the diaphragm's muscular origins and innervation. Normal chest x-rays show the diaphragm is 2-3 mm thick. Pathologies include diaphragmatic paralysis, ruptures from trauma, and hernias such as Bochdalek and Morgagni hernias. Tumors like leiomyosarcomas can also involve the diaphragm. Imaging plays a key role in evaluating diaphragmatic abnormalities.
3. THORACIC DIAPHRAGM (ANATOMY)
⢠Dome shaped
⢠Muscular fibres : orgin
Sternal â below XIPHOlD process ,
Costal - Inner surface of costal cartilages of
6th ribs ,
lumbar - Aponurotic arches of lumbar
vertebrae
4. ⢠lumbocostal arches : 2 pairs
Medial lumbocostal arches : tendinous arch covering psoas major;
continuous medially with left crura ; attached to L2 vertebral body
and in the front of the transverse process of L1 and L2
Lateral lumbocostal arches : covers quadratus lumborum;
attached medially to the L1 transverse process and attached
laterally to the tip of the 12th rib
⢠Crurae : Right and Left ; Blends to the Anterior longitudinal
ligament of vertebrae
⢠CENTRAL TENDON: Strong aponeurosis. below pericardium
5.
6. Aortic Hiatus (T12)
Oesophageal Hiatus (T10 )
Vena caval foramen (T8)
Lesser apertures
BLOOD SUPPLY
At
1.Costal margins â lower 5 intercostal A.
2. Abdominal surface â Rt & Lt Inf.Phrenic A.
3. Superior phrenic A. And Musculophrenic A
NERVE SUPPLY
Rt and Left phrenic N. & inter âcostal N.
9. ⢠Normal Diaphragm is 2-3 mm thick
⢠Which is normally not measurable In right side unless
there is free peritoneal gas or bowel loop separating
the liver from diaphragm.
⢠In the left side the combined stomach wall and
diaphragm form linear density of 5-8 mm thick.
⢠Thickening in most cases are normal.
⢠Pathological thickening is seen in
1. Tumors of diaphragm; stomach & pleura
2. Subpulmonary fluid
3. Diaphragmatic humps
4. Abdominal lesions : splenomegaly, Hepatomegaly
Sub-phrenic abscess
10. NORMAL VARIATIONS
⢠Scalloping: Rt side common;
⢠Muscle slips
⢠Dipahragmatic humps and
Dromedary hump
⢠Eventration
⢠Accessory Diaphragm
11. DIAPHRAGM (PHYSIOLOGY)
⢠Function : Seperation between Thoracic and Abdominal cavities.
Aid in Respiration as Chief Inspiratory muscle
⢠Two components : non contractile central tendon ;contracting muscle fibres
⢠Contraction of muscles induce intra-pleural pressure ď cause air to be sucked in the
lungs
⢠Contributes 3/4th of inspiratory volumes at the vital capacity.
⢠Normal movement is 3-5 cm
⢠Abnormal movement or reduced movement is seen in paralysis of diaphragm
⢠Movement of diaphragm can be assessed using USG or Flouroscopy
13. DIAPHRAGMATIC PARALYSIS
⢠Due to injury to Phrenic nerve.
⢠Unilateral or Bilateral
⢠Increase load can cause respiratory failure
⢠Assosciated with conditions like : Spinal cord transection, Multiple sclerosis, Amyotrophic lateral
Sclerosis, Cervical spondylosis GBS,
⢠Isolated Phrenic Nerve dysfunction: Compression by tumor, Cardiac surgery cold injury, blunt trauma,
etc.
14. ⢠Chest radiograph show elevated hemidiaphragm
and Atelectasis of lung
⢠Flouroscopy aid s in clear visualization of the
movement of the diaphragm
⢠Sniff Test: Parodoxical Elevation of diaphragm in
inspiration
⢠Other tests : PFT, EMG and phrenic nerve
stimulation
⢠USG
15. DIAPHRAGMATIC MOVEMENT
ASSESSEMENT THORACIC ULTRASOUND:
⢠Principles:
⢠Changes in diaphragm thickness during
contraction.
(chronically paralyzed diaphragm is atrophic and
does not thicken during inspiration )
⢠Should be assessed in two areas Liver at the
Right and Spleen window on the left
⢠Low frequency probes are used.
18. RUPTURE OF DIAPHRAGM
⢠Traumatic diaphragmatic injuries occur in 0.8%â8% of patients who sustain blunt trauma. Up to 90% of
diaphragmatic ruptures from blunt trauma occur in young men after motor vehicle accidents
⢠Both bilateral tears and extension of tears into the central tendon are uncommon. They are reported in
2%â6% of patients with diaphragmatic injury.
⢠Mechanisms of injuries include a lateral impact, and shears the diaphragm, and a direct frontal impact
19. ⢠Most ruptures are longer than 10 cm and occur at the
posterolateral aspect of the hemidiaphragm between
the lumbar and intercostal attachments and spread in
a radial direction
⢠Penetrating injuries such as gunshot wounds or stab
injuries are more random
Sites of injuries. Drawing shows radial (A), transverse
(B), and central (C) ruptures and a peripheral
detachment (D). Radial tears appear to be the most
frequently found injury at surgery, whereas
peripheral detachments are the least frequent.
20. ASSOSCIATED INJURIES
⢠Common : pelvic fractures (40%â55%), splenic
injuries (60%), and renal injuries
⢠High frequency of liver injuries, which are more
frequently associated with right than with left
diaphragmatic tears
⢠Thoracic injuries : pneumohemothoraces and rib
fractures are seen in 90% of patients. Aortic thoracic
injuries are reported in 5% of patients
21. DIAPHRAGM INJURY (IMAGING)
Chest X-ray :
(a) intrathoracic herniation of a hollow viscus (stomach, colon,
small bowel) with or without focal constriction of the viscus
at the site of the tear (collar sign)
(b) visualization of a nasogastric tube above the
hemidiaphragm on the left side
⢠Findings suggestive of hemidiaphragmatic rupture include
elevation of the hemidiaphragm, distortion or obliteration of
the outline of the hemidiaphragm, and contralateral shift of
the mediastinum
22. ⢠CT CHEST:
⢠Helical CT has proved to be more valuable in the detection of
diaphragmatic injuries with a sensitivity of 71%
⢠Findings :
⢠1. Direct discontinuity of the hemidiaphragm;
sensitivity 73%, specificity 90%.
⢠2. Intrathoracic herniation of abdominal contents;
sensitivity 55%, specificity 100%.
⢠3. The collar sign: sensitivity 36% with conventional CT
63% with helical CT. On the right side, the collar sign can
appear as a focal indentation of the liver, a subtle sign easily
overlooked
⢠4. The dependent viscera sign: sensitivity: 100%: left-
sided 83%: right-sided
when a patient with a ruptured diaphragm lies supine at CT
examination, the herniated viscera (bowel or solid organs)
are no longer supported posteriorly by the injured
diaphragm and fall to a dependent position against the
posterior ribs
23. CONGENITAL DIAPHRAGMATIC HERNIA
⢠Diaphragmatic hernias include Bochdalek
(posterolateral), Morgagni (retrosternal),
and hiatal hernias
⢠Antenatal USG scan can diagnose all
types earlier
⢠USG can in aid in determining the
survivability of the foetus.
⢠Congenital diaphragmatic hernia (CDH) is
a major surgical emergency in newborns.
The key to survival lies in prompt
diagnosis and treatment
⢠Pulmonary hypertension and Pulmonary
hypoplasia are complications
24. MORGAGNIâS HERNIA
⢠Anterior defect of the diaphragm
⢠Retrosternal, or parasternal hernia
⢠herniation through the foramina of Morgagni
⢠Associated pericardial defect , pleural and or pericardial effusion may b seen
⢠Contents : the liver, spleen, and omentum
⢠D/d s
Thymoma, Rt middle lobe collapse, hydatid cyst, fibrous tumor of the pleura
Cardiophrenic angle lesions:
lymphadenopathy : metastasis, lymphoma, reactional
Pericardial Cyst ; pericardial lipomatosis
25. MORGAGNI HERNIA
⢠Morgagni hernia in a 2-year-old child.
Lateral chest radiograph shows
herniation of a bowel loop (arrows) in a
classic location through an
anteromedial defect.
⢠Anterior herniation of bowel loops on a
lateral chest radiograph is the typical
finding. Other herniated viscera include
the liver, spleen, and omentum.
29. BOCHDALEK HERNIA
⢠Posterior aspect
⢠defect in the posterior attachment of
the diaphragm when there is a failure
of pleuroperitoneal membrane closure
in utero
⢠most frequently left sided.
30. BOCHDALEK HERNIA
⢠Frontal radiograph of the chest in a
newborn shows herniation of bowel
loops into the left hemithorax with
displacement of the heart to the right,
findings consistent with left Bochdalek
hernia.
⢠The nasogastric tube (arrows) in the
left hemithorax indicates the
intrathoracic stomach.
31. HIATUS HERNIA
⢠A .K.a. oesophageal hiatal hernia
⢠herniation of stomach through the oesophageal hiatus of the diaphragm
⢠Types
1. Sliding 2. roling (para-oesophageal)
Content : always Stomach ; rarely with bowel loops (if the defect is large enough)
D/ds
Lung abscess (Retro- cardiac)
Empyema , epiphrenic oesophageal diverticulum
35. CONGENITAL DIAPHRAGMATIC
EVENTRATION
⢠Abnormal elevation of part or all of an otherwise intact hemidiaphragm into the chest
cavity is termed eventration.
⢠CAUSES
congenital absence of muscle fibers
focal dyskinesia and weakness from ischemia, infarct,
neuromuscular dysfunction.
⢠The anteromedial aspect of the right side
⢠D/Ds
Morgagni hernia, pericardial cyst, paraesophageal hernia, bronchogenic cyst, and tumor.
36. ⢠Focal eventration (arrow) at the anteromedial aspect of the right hemidiaphragm.
⢠The eventration contains part of the liver.
37. ⢠Eventration (arrow) at the left
hemidiaphragm at seen at birth.
⢠Complete eventration of a
hemidiaphragm is more common in
males and typically occurs on the left
side.
39. PRIMARY BENIGN NEOPLASMS;
⢠Can arise from any of the normal tissue
components .
Eg: Lipomas, fibromas, angiofi bromas,
neurofibromas and neurilemmomas are
common;
Adrenal cortical adenoma, liver cell adenoma,
chondroma, hamartorna and mesothelioma
are rarer
⢠Diagnosed mostly post mortem biopsy,
⢠X-ray appearance as irregularity in
diaphragm
40. PRIMARY MALIGNANT NEOPLASMS
Majority are fibrous tissue origin.
Eg; (fibrosarcoma, fibro-myo-sarcoma, fibro-
angio-endothelioma) or undifferentiated
sarcomas.
⢠mixed cell sarcoma, myosarcoma,
rhabdomyosarcoma,
⢠Of the reported primary tumors of the
diaphragm, malignant neoplasms
predominate in a ratio of about 60 :40.
42. ⢠SECONADARY MALIGNANT NEOPLASMS
⢠Secondary malignant neoplasms of the diaphragm
may he due to direct invasion
⢠from adjacent lesions or metastatic spread OR
through vascular channels.
⢠Resembles benign tumours radiogrpahically.
⢠Blood born mets are rare
⢠Direct spread from lver ,lungs (incl pleura), stomach,
kidneys adrenaals are seen ;
⢠Others include chondro sarcoma , Hodgkinâs disease
Thoracic â seprates thoracic cavity from abdominal contents Pelvic â sep pelvic cavity from perineumUrogentital â old term for Triangular ligament which separates as a layer of the pelvis that separates the deep perineal sac from the upper pelvis
The sternal fibers a\ Interdigitates with Transversusabdominus muscles ,
lumbocostal arches : 2 pairs Medial lumbocostal arches : tendinous arch covering psoas major; continuous medially with left crura ; attached to L2 vertebral body and in the front of the transverse process of L1 and L2Lateral lumbocostal arches : covers quadratuslumborum; attached medially to the L1 transverse process and attached laterally to the tip of the 12th ribCrurae : Right and Left ; Blends to the Anterior longitudinal ligament of vertebrae
I 8 10 EGGS AT 12OR COUNT THE LETTER S
RIGHT DOME OF DIAPHRAGM IS HIGHER THAN LEFT DOME OF DIAPHRAGM ITS BECAUSE
Scalloping convexity up; muscle slips convexity down Acessory diaphragm was assosicated with liver accessory lobeMuscle slips in tall lean men or in emphysematous lungs
Diagnosed by CXr by Elevated diaphragm
Fig1 right side elevated diaphragm; Fig 2 same patient in fluoroscopy to assesesmovvemnt shows no change in level during inspiration as well as expiration of
Thr can also b pulmonary abnormalities related to the trauma such as pleural effusion, pulmonary contusion or laceration, atelectasis, and phrenic nerve palsy can mimic or mask diaphragmatic injury on chest radiographs.In somcases managements like ppv can suppress herniation.
The foramen of Morgagni (space of Larrey) extends from the sternum medially to the eighth rib laterally and occurs because of failure of complete fusion between the pars sternalis and the pars costalis of the hemidiaphragms.
The foramen of Morgagni (space of Larrey) extends from the sternum medially to the eighth rib laterally and occurs because of failure of complete fusion between the pars sternalis and the pars costalis of the hemidiaphragms foramina of Morgagni which are located immediately adjacent to the xiphoid process of the sternum.Associated pericardial defect contents Herniates into the pericardium The origin of the pericardial fluid is speculated to be the result of mechanical irritation of the pericardial mass. Venous obstruction in the liver, leading to congestion and transudation, could also be responsible
Fig 1 The liver (arrows) is herniated into the chest through an anterior defect in the diaphragm. Pericardial effusion surrounds the superior aspect of the herniated liver (short arrow).Fig 2 the appearance of pleural effusionsÂ
FLOUROSCOPIC IMAGING
FIG 1 SHOWS DEFECT IN DIPHRAGM WITH PERI HEPATIC FAT HERNIATING THROUGH IT Fig 2 shows another patientFIG 2
Epiphrenic diverticula are pulsion diverticula of the distal oesophagus arising just above the lower esophageal sphincter (LES), more frequently on the right side.They are less frequent than traction mid oesophageal diverticula, but may have more clinical relevance.  Barium meal is helpful in d/d
Fig 2 is a para oesophageal or rolling hernia with large defect wit bowel loops herniating into it .
The anteromedial aspect sof the right hemidiaphragm is the most common location for focal eventration and is uually occupied by part of the liver.
Lipoma as a lobulation in left hemi-diaphragm
a diaphragmatic mass was identified only During right thoracotomy, with multiple lesions over the pleura .
Diaphragmatic invasion by a primarymalignant liver tumor in a
Hematogeneous metastasis from an ovarian carcinoma. (A) Roentgenogram from 1967 showing anormal diaphragmatic contour. (B) Roentgenogram from 197! showing interval appearance of a lobu-Ia ted tumor-metasta tic ovarian carcinoma confined to the intramuscular portion of the diaphragm.
Ill defined margins are in favour for malignancy
Hydatid cyst classical calcifications noted. se
CT APPEARANCE OF DIAPHRAGMATIC SLIPS
HATAL HERNIA IN AZYGO-OESPHAGEAL RECESS
SILHOUETTE SIGN FIG 1 SILHOUETTTED
HYDROPNEUMOTHORAX WITH CYSTS ON LUNG
the abnormal right border of the heart.The right interlobar artery is not visible, because it is not surrounded by aerated lung but by the collapsed lower lobe, which is adjacent to the right atrium.right lower lobe atelectasis.
displacement of the azygoesophageal line.air within the hernia on the lateral view.
CDH
Lymphadenopathy and groundglass appearance of the lungs