a traumatic right diaphragmatic rupture as the result of blunt trauma is a rare condition .
the overall incidence of diaphragmatic rupture after blunt trauma is 0.8 - 3.6% ( 1 ) .
most injuries are due to vehicular - related incidents ( 79.5% ) and falling from a height ( 15.9% ) ( 2 ) .
right - sided tears are significantly less likely than left - sided tears , 27.3% and 68.2% respectively ( 3 ) . the correct diagnosis of diaphragmatic injury is initially missed in 12%-66% ( 1 )
delayed diagnosis and treatment of diaphragm rupture is associated with increased rates of morbidity and mortality . in our case
on our outpatient clinic , a 37-year - old man was presented with 31 years before a fall from a wall of 3 meters on his right side .
next to this major event the man was involved in a moped -car accident with only his face wounded , 18 years ago . during his life
the patient presented to us with primary complaints of progressive , stabbing pain in the upper right abdomen and right lower thorax with simultaneous periods of dyspnoea .
the symptoms worsened over a year , eventually leading to shortness of breath during rest . beside this presentation
the patient had right upper abdominal pain while eating spicy food . on admission , his vital signs were stable and colour was fair .
pulmonary examination revealed diminished breath sounds at the basal right hemithorax and the diaphragm was determined to be higher on the right by percussion .
the diagnosis was confirmed by thoracic - abdominal x - rays and computerised tomography ( ct ) imaging , which revealed intra - thoracic displacement of the liver and also the gallbladder ( figure 1 ) .
an elective thoracotomy in the sixth intercostal space was performed with repairing the diaphragmatic hernia ( figure 2 ) .
the liver with gallbladder was replaced in the abdominal cavity , after adhesiolysis of the lung from pleura and diaphragm , whereupon the diaphragm was closed tensionless by running technique with non - absorbable sutures .
two drains were left behind , one near the diaphragm and one in the right upper thorax .
right sided diaphragmatic rupture with consequently hepatothorax is a rare condition . blunt traumatic diaphragm rupture
a delay could result in increased rates of morbidity and mortality ( 5 ) . in case of hepatothorax , hypovolemic
shock can occur , because of possible kinking of the inferior vena cava with obstruction of the blood . in this case
there was a lateral impact on the chest , which distorted the chest wall and sheared the diaphragm .
there remains doubt about the cause of delayed diagnosis and treatment of this diaphragm injury , since it could occur as the result of either delayed rupture or delayed detection .
even if the herniation did not take place initially it would result in herniation eventually , because of the significant discrepancy between the intra - thoracic pressures and higher intra - abdominal pressure .
most of the diaphragmatic ruptures occur on the left side , because the right diaphragm is congenitally stronger than the left .
moreover the liver partially protects the right side as the impact can be spread over a large area .
pain in the upper abdomen and lower thorax , dyspnoea , cyanosis and hypotension are typical symptoms of diaphragmatic injury , but if the rupture is small the patient can remain symptom free for a long time .
the true incidence of traumatic diaphragm rupture is unknown because in 12 - 66% ( 1 ) of major trauma victims , the diagnosis is missed .
there is no consensus yet , on the gold standard of imaging technologies to diagnose diaphragm rupture .
based on the literature , diagnosis of diaphragmatic injury requires a high index of suspicion regardless whether you make an x - ray or ct .
the choice of surgical approach includes thoracotomy , laparotomy , or both if it is necessary .
the decision to repair the diaphragm either way is dictated by the stability of the patient and the presence of other associated organ injuries .
 a traumatic right diaphragmatic rupture is an uncommon condition , as it occurs in 0.8 - 3.6% after blunt trauma . 
 it is challenging to find the diagnosis immediately and is illustrated by the incidence of 12 - 66% initially missed diagnosis ( 1).most blunt traumatic diaphragm ruptures are an indication for early aggressive surgical intervention by way of thoracotomy , laparotomy , or both if it is necessary . 
 delayed diagnosis and treatment of diaphragm rupture is associated with increased rates of morbidity and mortality . 
 therefore , diagnosis of diaphragmatic injury requires a high index of suspicion . 
 we report a case of a 37-year - old man with right diaphragmatic rupture after blunt injury 31 years prior to admission . 
INTRODUCTION
CASE REPORT
DISCUSSION