The diagnosis is said to be clinical since it results in a SAHA HDAC life-threatening condition. Emergent needle decompression should be carried out before confirmation by chest x-ray when the patient is haemodynamic

instable. The incidence of diaphragmatic injury among patients with blunt thoracic and abdominal trauma is about 3%-5% [1]. In this case we suspect that the left diaphragmatic injury resulted from the patient’s fall from the stairs four weeks before his arrival find more at the emergency department. It is true that most diaphragmatic ruptures are due to high speed traffic accidents, but smaller accidents like a fall can cause the same type of injury [2]. Other etiologies might be an earlier trauma or a congenital posterolateral hernia (Bochdalek). The interval between diaphragmatic injury and the onset of symptoms can range from several weeks to years [3]. Left-sided rupture occurs approximately twice as often as right sided, due to protection PS-341 supplier of the liver [4]. When a traumatic diaphragmatic rupture is suspected a chest radiograph should be obtained because it remains the most sensitive method for diagnosis [5]. A computed tomography may show a discontinuity of the diaphragm, but it is not 100% sensitive. Herniation of intra-abdominal organs above the diaphragm is a possible

complication of a diaphragmatic rupture. Surgical repair is necessary because the rupture will not close spontaneously. An undiagnosed or unrepaired diaphragmatic rupture can cause future hernation of almost intra-abdominal organs. Early diagnosis is crucial which was proven in a retrospective study with diaphragmatic herniation after penetrating trauma. The mortality rate in the group with early presentation was 3% compared to 25% in the group with delayed presentation (with a median

of 27 months) [6]. A fecopneumothorax or a gastrothorax may rarely occur and may mimick the clinical presentation of a tension pneumothorax [3, 7]. In this case the tension pneumothorax was secondary to rib fractures. The dorsolateral rib fractures were pointing towards the left lung. The hypothesis that the initial tension pneumothorax was a tension fecopneumothorax due to earlier colonic perforation above the diaphragmatic hernia was not withheld because of absence of feces or bacterial growth in the initial drainage fluid. A tension fecopneumothorax is a very rare identity and so far only 12 case reports have been published [8, 9]. The perforation of the transverse colon was due to prolonged suction on the chest tube thus causing adherence and perforation of the herniated colon, resulting in a fecopneumothorax. As proven in this case a chest tube under prolonged suction might create an iatrogenic herniation of intra-abdominal organs and even perforation when a diaphragmatic rupture is present. Conclusion In this case the presentation of the tension pneumothorax was subacute because the air was able to escape through the diaphragmatic rupture towards the peritoneum.