Traumatic injuries of the diaphragm are relatively uncommon after blunt trauma, as such are frequently missed after initial assessment and treatment1–4,, . The different mechanisms that result in diaphragmatic rupture after blunt trauma included avulsion of the attachments of the diaphragm or shearing of the stretched membrane after right or left lateral impact to the chest wall, rib fracture fragments directly penetrating the diaphragm, and a sudden increase in intra-abdominal pressure throughout the abdomen, with the relatively weak, unprotected diaphragmatic tear from the force5,. Right-sided hemidiaphragmatic ruptures are particularly prone to delayed diagnosis or even go undetected for years and are thus,subject to delayed surgery 1, 3. The left hemi-diaphragm has been shown to be injured in 50–88% of patients who had blunt diaphragmatic rupture whereas right sided injuries were less frequent, occurring in 12–40% of cases5,10. The right diaphragm appears to be protected from traumatic impact by the energy absorbing liver, thus accounting for the lower incidence of right sided ruptures 5,6. Right sided ruptures are also, frequently missed and thus may present with late symptoms 1. The high frequency of left sided injuries has been attributed to an area of congenital posterolateral weakness 5,7−10 .
An early and accurate diagnosis of diaphragmatic injury in the setting of blunt and penetrating trauma can be difficult even with the help of sophisticated diagnostic modality5,6,. Computed tomography is the main stay in the diagnosis of such injuries, which may be subtle at presentation. Key features in blunt trauma include diaphragma fragment distraction and organ herniation because of increase intra-abdominal pressure 1,5,6. The index patient had an initial delay due probably to the head injury with loss of consciousness he had at the initial presentation. The subsequent ten year diagnostic delay could be due to the atypical presentation and those who attended to him during that period could not link his symptoms to the trauma which appeared remote from his symptoms. An early CT scan could have saved him this period of delay.
Operative intervention remains the main stay management approach for traumatic diaphragmatic ruptures regardless of the presentation, whether early or late to avoid complications that might arise from the presence of abdominal viscera in the chest. Surgical repair is also required in all diaphragmatic ruptures because the diaphragm does not heal spontaneously. The thoracic approach is usually recommended for chronic diaphragmatic hernias due to dense intra-thoracic adhesions that could be encountered in such cases as well as in right sided rupture due to the ease of access to the operating field as the liver would prevent adequate access from the abdomen1,3, 6. With experience however, both approaches are viable especially in the initial presentation. The thoracic approach could be achieved either by Video assisted thorachoscopic surgery (VATS) or through a thoracotomy. Combined chest and abdominal approaches have been employed in some cases4–7,9. Laparoscopic surgery is another approach in the treatment of traumatic diaphragmatic ruptures in institutions where the facilities and expertise are available.