• Diaphragmatic injuries are often caused by penetrating injuries. • Patients sustaining penetrating injuries below the nipples and above the costal margins should be investigated to rule out diaphragmatic injury. Etiology • Penetrating trauma (knife, bullet, repair of hiatus hernia) • Blunt trauma (motor vehicle accident, fall from height, bout of hyperemesis): −− Caused by compressive force applied to the pelvis and abdomen. −− Rupture is usually large, with herniation of abdominal content into chest Clinical Features • Most diaphragmatic injuries are silent and the presenting features are those of injury to the surrounding organs. • Late complication: Herniation of abdominal contents in to the chest. • Herniation of organ: Stomach >Colon >Small intestine >Omentum >Spleen >Kidney and pancreas. Diagnosis • There is no single standard investigation to diagnose diaphragmatic injuries. • Chest X-ray after placement of a nasogastric tube may be helpful (as this may show the stomach herniated into the chest) • Contrast study of upper or lower GIT, CT scan and diagnostic peritoneal lavage all lack positive or negative predictive value. • Most accurate evaluation is by video assisted thracoscopy (VATS) or laparoscopy, offering the advantage of allowing the surgeon to proceed to repair and additional evaluation of the abdominal organs. Treatment • Operative repair is recommended in all cases. • All penetrating diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out penetrating hollow viscus injury. Bergvist Triad: Rib fracture + Fracture of spine /pelvis + Traumatic rupture of diaphragm