Diaphragm

Diaphragm
• The diaphragm partitions
the thorax from the
abdomen.
• It is a musculotendinous
structure i.e. it is
composed of a peripheral
muscular portion which
inserts into a central
aponeurosis at the
central tendon.
 Development
• The diaphragm is formed by fusion of the
following in the embryo.
• the septum transversum (forming the central
tendon);
• the dorsal oesophageal mesentery;
• a peripheral rim derived from the body wall;
• the pleuroperitoneal membranes, which close
the foetal communication between the pleural
and peritoneal cavities.
 Origin
• Sternal part: Two slips attached to post. surface of xiphoid
process
• Costal part: slips arising from inner aspects of lower 6 costal
cartilages
• A vertebral part: this comprises the crura and arcuate
ligaments.
• right crus: from bodies of L1 to L3 and vertebral disc
• left crus: from bodies of L1 & L2
• Med arcuate ligament: thickening of psoas fascia
between body of transverse process of L1
• lat arcuate ligament: from transverse process of LV1 to middle
of lower border of 12th rib
 Insertion
• The fibres pass upwards
to insert into central
tendons, which is
trifoliate.
• Levels: Rt. dome: upper
border of 5th rib
• Lt. dome: lower border
of 5th rib
• Central tendon: at level
of xiphisternal joint.
 Nerve Supply
• Motor supply: the entire motor supply arises
from the phrenic nerves (C3,4,5).
• Sensory supply: the periphery of the
diaphragm receives sensory fibres from the
lower intercostal nerves (by lower 6
intercostal nerves)
•  
 Actions
• muscle of inspiration
• bad straining
• weight lifting muscle
• thoraco-abdominal pump
•  Function: contract  increases thoracic vol
 inspiration
• It is the chief muscle of respiration.
 Openings in Diaphragm
• • T8, the opening for the inferior vena cava: transmits
the inferior vena cava and right phrenic nerve.
• • T10, the oesophageal opening: transmits the
oesophagus, vagi and branches of the left gastric
artery and vein and lymphatics.
• • T12, the aortic opening: transmits the aorta,
thoracic duct and azygos vein.
• The left phrenic nerve passes into the diaphragm as a
solitary structure thru the left dome.
 Other Structures Transmitted
• Behind med arcuate ligament , symph trunk and psoas major
• behind lat arcuate ligament: subcostal vessels & n and
quadratus lumborum
• Sternocostal hiatuses: Located at the level of T 10, between
the muscle of the sternal origin and the costal origin:
transmits the superior epigastric vessels.
• piercing crura: splanchnic nn and i/c lymph trunks
• piercing L dome: L phrenic n
• piercing costal origin: neurovascular bundles of T7 to T11 i/c
spaces
 Clinical Notes
• Accumulation of infected materials in
subphrenic spaces
•  Pain Referral : Because the innervation to the
diaphragm(motor and sensory)is primarily from
(3 through 5 spinal nerves, pain arising from
the diaphragm (e.g. subphrenic abscess) is
referred to these dermatomes in the shoulder
region.
 Diaphragmatic hernias
• Through the foramen of Morgagni; anteriorly
between the xiphoid and costal origins;
• Through the foramen of Bochdalek—the
pleuroperitoneal canal—lying posteriorly;
• Through a deficiency of the whole central tendon
(occasionally such a hernia may be traumatic in
origin);
• Through a congenitally large oesophageal hiatus.
 Acquired hernia
• Far more common are the acquired hiatus
herniae (subdivided into sliding and rolling
herniae).
• These are found in patients usually of middle
age where weakening and widening of the
oesophageal hiatus has occurred.
 sliding hernia
• In the sliding hernia the upper
stomach and lower oesophagus
slide upwards into the thorax
through the lax hiatus when the
patient lies down or bends over.
• The cardia is often incompetent
this allows peptic juice to
regurgitate into the oesophagus
when lying down or bending
over.
• Oesophagitis with subsequent
heartburn, bleeding and,
eventually, stricture may occur.
 Rolling hernia
• This is less common. The
cardia remains in its
normal position and the
cardio-oesophageal
junction is intact.
• The fundus of the stomach
rolls up through the hiatus
in front of the oesophagus.
• There may be epigastric
discomfort, flatulence and
even dysphagia, but no
regurgitation.
• The sensory nerve fibres from the central part
of the diaphragm also run in the phrenic
nerve, hence irritation of the diaphragmatic
pleura (in pleurisy) or of the peritoneum on
the undersurface of the diaphragm by
• subphrenic collections of pus or blood
produces referred pain in the corresponding
• cutaneous area, the shoulder-tip.
• Injury or operative division of this nerve
results in paralysis and elevation of the
corresponding half of the diaphragm.
• Radiographically, paralysis of the diaphragm is
recognized by its elevation and paradoxical
movement i.e. instead of descending on
inspiration it is forced upwards by pressure
from the abdominal viscera.