The studies published before 1996 have quoted that 12–69% of diaphragmatic ruptures are missed at the pre operative phase [
38‐
40]. CT scan was not widely used investigation when these papers were published. However, with the introduction of reformatting of images the sensitivity of the CT scan in picking up the diaphragmatic rupture has significantly increased[
41]. While audible bowel sounds on the chest auscultation suggests displaced bowel loops, a chest x ray is the first line of investigation, repeated imaging increases sensitivity[
8]. Insertion of a naso-gastric tube can decompress the intra-thoracic stomach to delineate a chest x ray interpretation [
8,
29] and increase the diagnostic sensitivity to approximately 75%[
8]. The sensitivity of chest radiographs is 46% for left sided ruptures and 17% for right sided ruptures [
42]. Helical CT with axial, sagittal and coronal reconstruction increases the sensitivity to 73% and the specificity to 90%[
12]. A diagnostic laparoscopy and/or diagnostic thoracoscopy could be performed as a semi-elective procedure, the timing planned in accordance with the heamodynamic and respiratory status of the patient [
27,
28]. Meticulous inspection and palpation of the diaphragm should be performed during laparotomy in patients with trauma [
12].
The systematic review of literature confirmed chest x ray findings of bowel loops in the left hemithorax [
12,
13], abundant hydropneumothorax [
21], elevation of the left diaphragmatic dome[
7,
18,
33], loculated left pneumothorax [
8], mediastinal shift [
16], free gas under the diaphragm [
18] and subdiaphragmatic densities [
18]. The abdominal x ray findings reported features of large bowel obstruction [
18]. Contrast X ray has been reported as showing large part of the stomach lying in left chest [
17]. Intrapleural herniation of large intestine has been reported as CT scan findings of intrapleural herniation of large intestine and abundant pleural effusion [
21], Intrathoracic displacement of liver[
12,
15,
33], intrathoracic spleen with splenic vein thrombosis [
22], large right diaphragmatic rupture with herniation of liver, gall bladder, right kidney, ureter and renal vein. Along with distal ascending colon and proximal transverse colon[
7], Collar Sign (Waist like constriction) is produced by compression of herniated organs [
10,
16]. Diaphragmatic discontinuity and dependent viscera sign (abdominal organs set against the posterior ribs) [
10,
43] have also been reported. Pleuro-pulmonary sonography has been used in one case to confirm condensed lung with pleural effusion along with interruption of right hemidiaphragm with intrathoracic hepatic parenchyma, dilatation of hepatic veins and collapse of IVC with inspiration[
15]. Intraperitoneal injection of technetium sulphur colloid can be used to diagnose rupture of right diaphragm[
44]. MR scan has been performed and reported displacement of the liver [
32].