Traumatic right diaphragmatic rupture with hepatothorax: a diagnostic challenge!

Traumatic injuries of the diaphragm remain an entity of difficult diagnosis especially when it comes to the right diaphragm. It is a recognized consequence of high velocity blunt trauma to the abdomen, usually as a result of road traffic collisions or lateral intrusions into the vehicle and occasionally, penetrating thoraco-abdominal trauma. It has been reported that the rate of initial missed diagnosis of traumatic diaphragmatic injury ranges from 12% to 63% on CT (1). A missed diagnosis is associated with a mortality of 30% to 60% due to late presentation of intrathoracic visceral herniation and strangulation (2,3). After a high speed motor vehicle accident, a 30-year-old Saudi male was received in the trauma room. He was confused, hypotensive and in respiratory distress. The initial diagnostic workup included chest X-ray and full body non-contrast spiral CT scan, revealing fracture of the nasal bone and right hemothorax. No other radiological findings were detected in the initial assessment. Due to an assumed massive rightsided hemothorax (Figure 1), a thoracic tube was inserted and 750 mL of blood coming in the chest drain. After initial stabilization the patient was then transferred to the surgical unit of Sabya General Hospital, Saudi Arabia.