Post-traumatic diaphragmatic injuries can present as diaphragmatic hernia with herniation of abdominal viscera into the thoracic cavity. It is challenging for trauma surgeons to identify the delayed presentation of post-traumatic diaphragmatic injuries which require a high index of suspicion in patients who are at risk. We report a rare case of delayed diagnosis and management of post-traumatic diaphragmatic hernia in a polytrauma patient with a concise review of the literature. The patient presented after two years of post-traumatic thoracoabdominal injury due to a road traffic accident with breathing difficulty. On investigations, it was a large diaphragmatic hernia with herniation of abdominal contents into the left thoracic cavity. Laparotomy was performed with a reduction of abdominal contents from the left side of the chest along with mesh repair of the large diaphragmatic hernia. Postoperatively, the patient recovered well. The literature suggests that there should be a high level of suspicion of diaphragmatic injuries, especially when dealing with thoracoabdominal trauma or polytrauma patients. Post-traumatic diaphragmatic injuries, though rare, can lead to high morbidity or mortality if not treated on time.

UNASSIGNED: To investigate the diagnosis and surgical therapy of delayed diaphragmatic rupture.
UNASSIGNED: Forty patients with traumatic diaphragmatic rupture with delayed presentation and diagnosis were collected in Peking Union Medical College Hospital from 2000 to 2018, and a retrospective analysis was performed.
UNASSIGNED: In all forty patients, 36 (90%) patients had a traumatic past history, and 32 (80%) patients had clinical manifestations when diagnosed. Left-sided diaphragmatic rupture was found in 32 (80%) patients and right in 8 (20%) patients. One patient received emergency surgery, and 39 received selective surgery. Thirty-eight patients received thoracotomy, and 2 patients received combined thoracic-abdominal surgery. Thirty-six patients received direct diaphragm suture, and 4 patients received mesh repair. One patient had an intestinal obstruction and received enterolysis 19 days after surgery. During follow-up, 1 patient experienced recurrence 2 years later.
UNASSIGNED: Careful recording of past history and physical examination are the best approaches in diagnosing delayed presentation of traumatic diaphragmatic rupture. CT scan with reconstruction of the diaphragm is helpful in both diagnosis and differential diagnosis. Surgical therapy after diagnosis is the best treatment.

BACKGROUND: Diaphragmatic rupture (DR) is an uncommon, potentially serious complication following blunt or penetrating abdominal trauma. Even with a high index of suspicion, the diagnosis of DR can easily be missed for a long period post injury. Delayed or missed diagnosis [delayed diagnosis of diaphragmatic rupture (DDDR)] and delayed diaphragmatic rupture (DDR) are possible explanations in cases where the initial operative exploration fails to show the diaphragmatic damage.
METHODS: Here we present a patient with suspected DR that was not seen on initial open abdominal exploration, but was suggested by subsequent serial imaging. This injury was ultimately identified on laparoscopic exploration. The procedure was converted to open (celiotomy) due to poor tolerance of the pneumoperitoneum required for laparoscopy, and the laceration was primarily repaired. We propose that DDR and DDDR be considered as a differential diagnosis in patients with a previous thoraco-abdominal trauma when presenting with radiologic/clinical signs suspicious for DR, even when the immediate post traumatic exploration failed to demonstrate a DR.
CONCLUSIONS: A high index of suspicion is essential for early detection of DDR and DDDR. Patients with high impact injuries or surrounding organ damage should be followed with serial clinical examinations, follow-up radiologic assessments, and even re-exploration in situations highly suspicious for diaphragmatic injuries.