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Traumatic diaphragmatic injury
A diaphragmatic tear is a "silent" injury that is easy to miss — it is more common on the left, shows on the chest X-ray as stomach or a nasogastric tube above the diaphragm, and in penetrating injury at the left thoracoabdominal junction the safe diagnosis is diagnostic laparoscopy; an acute tear is repaired through the abdomen and an old one through the chest.
Why it matters in the exam
Diaphragmatic rupture follows blunt trauma (mainly road crashes with a sudden rise in intra-abdominal pressure) or penetrating injury (stab or gunshot). In blunt trauma the left side is injured in most cases, because the liver protects the right hemidiaphragm. The exam usually shows a chest X-ray with a nasogastric tube ending in the left chest, an "elevated" left hemidiaphragm or bowel loops in the chest. CT detects large tears but may miss small ones, so for a penetrating wound in the lower left chest (below nipple level in front and below the scapular tip behind) in a stable patient diagnostic laparoscopy is performed even when CT is normal; a small unrepaired tear enlarges with time and leads to a hernia with strangulation.
As for approach: in an acute injury the repair is done through laparotomy or laparoscopy, because most cases have associated injuries to the spleen, liver, stomach or bowel, and the repair uses non-absorbable sutures, sometimes with mesh for a large defect. In late presentation — months or years after the injury, with stomach, colon or spleen herniated into the chest — the preferred approach is through the chest (thoracotomy or VATS) because of adhesions between the herniated organs and the lung. A life-threatening situation is "tension gastrothorax" — a distended stomach in the chest that shifts the mediastinum and mimics tension pneumothorax; a nasogastric tube decompresses it, and a chest drain is inserted with great care because it may enter the stomach.
Distinguish congenital diaphragmatic hernias: Bochdalek (posterolateral, mostly left, in newborns) and Morgagni (anterior, mostly right, in adults).
Key points
- Diaphragmatic rupture is more common on the left.
- NG tube in the chest on X-ray — key sign.
- Penetrating left thoracoabdominal wound — diagnostic laparoscopy.
- Acute — through the abdomen; late — through the chest.
- Tension gastrothorax — NG tube first.
Summary table
| Situation | Typical finding | Approach |
|---|---|---|
| Acute blunt trauma | NG tube in the left chest, elevated hemidiaphragm | Laparotomy and repair, inspect the abdominal organs |
| Penetrating wound at the left thoracoabdominal junction, stable patient | CT may be normal | Diagnostic laparoscopy |
| Late presentation with hernia | Stomach or bowel in the chest, obstruction or strangulation | Approach through the chest because of adhesions |
| Tension gastrothorax | Mediastinal shift, mimics tension pneumothorax | NG tube decompression, chest drain with care |
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Sources
- ATLS Advanced Trauma Life Support Student Course Manual, 10th edition (2018) — Thoracic trauma and abdominal and pelvic trauma
- EAST Practice Management Guideline: Diagnosis and management of traumatic diaphragmatic injuries, 2018 — Recommendations
- Mattox, Moore, Feliciano: Trauma, 9th edition (2020) — Diaphragm injuries
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.