Duchenne’s sign is characterized by inward (paradoxical) movement of the epigastrium during inspiration. It suggests underlying diaphragmatic paralysis or fluid accumulation in the pericardium, leading to impaired diaphragmatic or cardiac mechanics.

Pathophysiology

• Normal physiology: During inspiration, contraction of the diaphragm causes the epigastrium to move outward as the abdominal viscera are displaced downward.

• Diaphragmatic paralysis: The diaphragm fails to contract effectively; instead of pushing abdominal contents down, negative intrathoracic pressure pulls the epigastrium inward.

• Pericardial effusion or tamponade: Accumulated fluid restricts diaphragmatic and cardiac motion, producing paradoxical epigastric retraction.

Examination Technique

Patient Positioning

• Place the patient supine with the chest and upper abdomen exposed.

Inspection

• Observe the epigastrium while the patient performs quiet breathing.

• Look for paradoxical inward motion of the epigastrium during inspiration.

Adjunct Assessment

• Assess diaphragmatic excursion by percussion or fluoroscopy if available.

• Correlate with signs of pericardial effusion (muffled heart sounds, jugular venous distension, hypotension).

Clinical Utility

• Diagnostic clue for diaphragmatic paralysis (unilateral or bilateral).

• Indicator of pericardial fluid accumulation and possible cardiac tamponade.

• Useful as a bedside sign in settings without immediate imaging.

Differential Diagnosis

Pediatric considerations

• May be observed in congenital diaphragmatic paralysis or after birth trauma affecting the phrenic nerve.

• Requires imaging (chest X-ray, ultrasound, fluoroscopy) to confirm diagnosis.

Geriatric considerations

• More common in older adults with comorbidities such as COPD, cardiac disease, or prior thoracic surgery.

• May herald respiratory muscle weakness or cardiac complications.

Limitations

• Inward epigastric movement may be subtle in obese patients.

• Must be distinguished from paradoxical chest wall movement due to flail chest.

• Requires confirmatory tests (ultrasound, fluoroscopy, echocardiography).

Patient counseling

• Explain that abnormal abdominal movement may reflect weakness of the diaphragm or fluid around the heart.

• Stress the need for further diagnostic tests (e.g., echocardiogram, chest imaging).

• Reassure the patient that recognition of this sign helps guide appropriate treatment.

Conclusion

Duchenne’s sign is a clinical indicator of diaphragmatic dysfunction or pericardial effusion, manifested by inward epigastric movement during inspiration. Though subtle, it remains a valuable bedside finding that should prompt further cardiopulmonary evaluation.

References

1. Duchenne GB. Physiologie des mouvements démontrée à l'aide de l'expérimentation électrique et clinique. Paris: Baillière; 1867.

2. Ropper AH, Samuels MA, Klein JP. Adams and Victor’s Principles of Neurology. 11th ed. McGraw-Hill; 2021.

3. Braunwald E, Zipes DP, Libby P, Bonow RO. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022.

4. Estenne M, et al. Diaphragmatic paralysis. Am Rev Respir Dis. 1985;132(1):48–52.