Slide 1: Question 1. Your patient has this portable chest x-ray as part of a trauma series. Does anything look funny?

Slide 2: There is a contour deformity of the right diaphragm (arrows pointing to contour deformity on x-ray). Compare to the normal left side. Question 2. What might be going on and what would you do next to better evaluate the diaphragm?

Slide 3: In the trauma setting, an abnormal diaphragmatic contour should raise the possibility of a torn diaphragm. Seen best on the coronal and sagittal cuts of a CT scan, the “pinching” (collar sign) of herniated abdominal contents can be seen here, where the arrows indicate the liver herniating into the chest. Question 3. Which side of the diaphragm is more commonly torn in the trauma setting?

Slide 4: The left diaphragm is more commonly torn than the right. A dramatic example is shown below, with herniation of the stomach into the chest. It takes a lot of force to tear the diaphragm, and patients often have multiple injuries. This coronal CT shows both a traumatic aortic injury (purple arrow) and herniation of the stomach (blue arrow) into the chest. Question 4. Why don’t the abdominal contents mind their own business and stay in the abdomen?

Slide 5: Remember, when we breath, we create negative intra-thoracic pressure with each inspiration. This pressure gradient draws abdominal contents through a hole in the diaphragm and into the chest.