Blunt Diaphragmatic Rupture

Chest radiograph in a young female sustaining bike vs. car trauma showed an abnormal course of the nasogastric (NG) tube (arrowheads) with the tip (arrows) overlying the lung, instead of being in the abdomen. There are multiple lucencies in the left lower hemithorax with indistinct diaphragm margin. Findings are diagnostic of left diaphragmatic rupture with herniation of stomach and bowel loops.

Differential diagnoses when NG tube tip overlies the chest:

• Tip still in stomach - diaphragm rupture (as in this case)
  
• Tip outside GI tract - in bronchus, pleural space
  
• Tube is outside of patient

Facts:

• Blunt diaphragmatic trauma occurs in left > right side (adult).
  
• In children, and in penetrating trauma; there is no side predilection.
• Many diaphragmatic trauma is diagnostic on chest radiographs if there is significant bowel herniation. Some can be difficult to detect.
• Specific plain radiographic signs are NG tube tip above the diaphragm and visceral herniation (usually air-filled bowel) with a focal constriction ('collar sign')

Reference:

Sliker CW. Imaging of diaphragm injuries. Radiol Clin North Am. 2006;44:199-211