A 24-year-old man presented to the emergency department after falling down from the fourth floor of a building on a construction site. Upon arrival he was alert, but dyspnoeic. The breath sounds over the left side of the chest were decreased. A chest radiograph was taken and revealed elevation of the left side of the hemidiaphragm (fig 1). Computed tomography of the chest was arranged to determine the severity of the lung injury (fig 2).

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Figure 1 Chest radiograph showing an arch-like curvilinear density indicating elevation of the left hemidiaphragm.

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Figure 2 CT scan showing herniation of intra-abdominal organs into the left thoracic cage.

The incidence rates of traumatic diaphragm rupture is between 0.8–1.6% of patients admitted because of blunt trauma.1 Left-sided rupture is more common than right-sided rupture (68.5% vs 24.2%).2 Hepatic protection of the right side, increased strength of the right hemidiaphragm, and weakness of the left hemidiaphragm at points of embryonic fusion all contribute to the predominance of left-sided diaphragmatic rupture.3 A delayed diagnosis of diaphragm rupture and its associated injuries to the chest wall, abdominal cavity, and pelvic cavity can result in life-threatening sequelae. Surgery should be performed as soon as the clinical diagnosis is made, either through the transabdominal approach or via thoracotomy.