{'fraction_non_alphanumeric': 0.019961612284069098, 'fraction_numerical': 0.012859884836852208, 'mean_word_length': 5.210965435041716, 'pattern_counts': {'":': 0, '<': 2, '<?xml version=': 0, '>': 3, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A tale of traumatic diaphragmatic hernia

Diaphragmatic injuries were described by Sennertus in 1541. Riolfi has done first successful repair in 1886. A traumatic diaphragmatic hernia is uncommon which accounts for 0.8 to 1.6%. In Blunt or penetrating abdominal injury, the patient presents as early or delayed respiratory distress or obstruction. Respiratory distress mainly due to pneumothorax or hemothorax, herniation of intra-abdominal organs and injury to the lung parenchyma. Abdominal pain due to strangulation of hernial content can occur earlier but mostly delayed presentation. The mortality mainly confides on associated injuries. Diagnosing the condition is high suspicion even with investigation modalities available. Surgery is the mainstay of treatment.


INTRODUCTION
Diaphragmatic injuries were described by Sennertus in 1541. Riolfi has done first successful repair in 1886. A traumatic diaphragmatic hernia is uncommon which accounts for 0.8 to 1.6%. 1 In Blunt or penetrating abdominal injury, the patient presents as early or delayed respiratory distress or obstruction. 2 Respiratory distress mainly due to pneumothorax or hemothorax, herniation of intra-abdominal organs and injury to the lung parenchyma. Abdominal pain due to strangulation of hernial content can occur earlier but mostly delayed presentation. The mortality mainly confides on associated injuries.
Diagnosing the condition is high suspicion even with investigation modalities available. Surgery is the mainstay of treatment.
abdomen, restricted left shoulder movement and abnormal mobility of shaft of left tibia and fibula.   Her echocardiogram shows stable cardiac status. Suggesting of traumatic diaphragmatic hernia, the patient was taken for emergency surgery after informed high-risk consent laparotomy was made intact stomach, transverse colon, omentum reduced with no injuries. (   The patient recovered well and discharged on a postoperative day 13.
Reviewed after 4 weeks, she had no complaints and able to do routine activities without any discomfort.

DISCUSSION
Traumatic diaphragmatic hernia is mainly due to blunt or penetrating injuries to the abdomen depending on the velocity of injury. The left side of the chest is commonly affected than the right side because of the protective effect by the liver. 3 They may present as chest pain, dyspnea in an acute setting due to pneumothorax, on examination decreased air entry, the condition when air leaks into space between lung and chest wall due to blunt or penetrating chest injury or present late due to the magnitude of other multiorgan injuries as hemothorax, pneumonia, sepsis, deep vein thrombosis. 4 Mechanism of injury is due to an increase in intraabdominal pressure as a result of trauma, shearing and avulsion. The positive pressure gradient between the intraperitoneal and intrapleural cavity of 7-20 cm H2O forces the abdominal content into the thorax, with severe trauma the pressure gradient may raise to 100 cm H2O. 5,6 American association for the surgery of trauma (AAST) classified diaphragmatic injury scale as Grade 1 contusion, Grade 2 laceration <2 cm. Grade 3 laceration 2-10 cm, Grade 4 laceration >10 cm with tissue loss <25 cm 2 , Grade 5 laceration with tissue loss >25 cm 2 . 7 Grimes proposed diaphragmatic rupture in 3 phases: acute phase patients with polytrauma (multiple intraabdominal and chest injuries), latent phase undetected diaphragmatic rupture or rent where herniation occurs, obstructive phase where herniated loop got obstructed. 8 High clinical index of suspicion is needed to diagnose and effectively manage diaphragmatic rupture even with a remote history of high-velocity injury. A plain chest x-ray may show the nasogastric tube in the chest and bowel gas shadow in the chest with the elevation of hemidiaphragm (collar sign), CT thorax shows the elevation of hemidiaphragm >4 cm on the affected side with the abdominal content, with contrast, increased sensitivity and specificity in visualizing content and rupture if any. 9 Focused assessment sonography in trauma (FAST) can be used in diagnosing diaphragmatic hernia. 10 However, in the absence of hernia, it may be difficult to identify diaphragmatic injury by conventional imaging.
We managed this case by laparotomy and reduction of content followed by a thorough examination for injuries. Small rent in the diaphragm can be managed with simple suturing with non-absorbable material, large defects may require mesh fixation. 11 Laparotomy is superior to thoraco laparotomy in the case of polytrauma as there could be associated with intraabdominal injuries. Laparotomy should be preferred in unstable patients.

CONCLUSION
This patient referred from other centres without ICD insertion despite suspected pneumothorax, where insertion of ICD could have been harmful rather than beneficial in this case. Abdominal approach is sufficient rather than a thoracoabdominal approach given associated intraabdominal injuries. A smaller diaphragmatic defect can be closed with interrupted non-absorbable suture as carried out in this case. Larger defects are managed mesh superimposition after primary closure. Nowadays minimal access approaches preferred.