A 40 F presents to the ED with severe L shoulder pain and epigastric pain after a restrained driver MVC in which her car struck a tree. On arrival, she is normotensive, tachycardic, tachypneic and spo2 is 93% on RA. A CT chest/abd/pelvis is obtained. What's the diagnosis?  (scroll down for answer)

 Answer: Traumatic rupture of the L hemidiaphragm

• CT above shows traumatic rupture of the L hemidiaphragm resulting in herniation of the stomach and bowel loops into the L chest cavity
• Patients often present with epigastric pain, back pain or shoulder pain
• Uncommon injury, diagnosis may be delayed
• L sided rupture more common than R due to protective nature of liver
• Unlikely to be a cause of early death in blunt trauma patients, but often associated with other serious injuries
• Management is surgical

References:  Petrone P., Asensio J. A., Marini C. P. Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Current Problems in Surgery. 2017;54(1):11–32.