The central tendon of the diaphragm is a trefoil-shaped aponeurotic sheet into which the muscular fibres of the diaphragm insert. It has no bony attachment, instead being held superiorly by the pericardium and inferiorly by the oesophageal hiatus. It is the point of force convergence during every inspiratory effort.
The central tendon contains the caval hiatus through which the inferior vena cava passes at T8. It is the site of pericardial attachment and is involved in pericardiodiaphragmatic injuries. Diaphragmatic hernias at the central tendon (type IV hiatus hernia) are rare but produce severe mediastinal displacement. Laparoscopic repair uses the central tendon as a reference point for hiatus repair.
Traumatic tearing of the central tendon and surrounding diaphragmatic muscle from blunt abdominal trauma, allowing abdominal viscera to herniate into the thorax with respiratory compromise.
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