posttraumatic diaphragmatic rupture was first described by sennertus in 1541 , but successful surgical treatment was described much later , by ralfi in 1886 . a study performed by carter et al .   revealed that most diaphragmatic ruptures are caused by blunt injuries ( 75% ) , and the rest are the result of penetrating injuries . about 80 - 90% of diaphragmatic ruptures the defect is usually localized in the left posterolateral aspect of the muscle ( bochdalek 's foramen ) ( 85 - 90% of cases ) . right - sided congenital diaphragmatic herniation occurs in 5 - 10% of cases , and is usually associated with delayed presentation of non - specific symptoms . a 13.5-year - old girl was admitted to the pediatric surgery department from the pediatric department of the district hospital , where she was admitted the previous day , because of stomachache and vomiting . thorough medical interview revealed blunt injury of the epigastrium caused by a ball a week ago , and an episode of stomachache and emesis a few months ago . physical examination revealed tenderness of the right epigastrium , significant reduction of the vesicular murmur on the right side of the chest and no peristalsis . chest and abdomen x - ray examination revealed a loss of the right diaphragmatic outline , irregular radiolucency with a fluid level on the right side of the chest , collapsed right lung and mediastinal displacement to the left ( fig . preoperative chest x - ray the nasogastric tube was visualized inside the stomach , below the left diaphragmatic outline ( fig . scan showed a small ( several centimeters ) defect of the right diaphragm and dislocation of the intestines and greater omentum into the chest and also liver displacement to the left ( fig . preoperative chest x - ray with nasogastric tube preoperative chest ct scan aspartate transaminase ( ast ) and alanine transaminase ( alt ) activity and the total concentrations of bilirubin and crp were slightly elevated . because of persistence of stomachache and volvulus symptoms , the patient was operated on . herniation of the intestines and half of the stomach into the defect in the posterolateral part of the right dome of the diaphragm was revealed . the diaphragm was cut along the course of the right diaphragmatic artery and the volvulus of half of the stomach , the transverse and a large part of the ascending and descending colon and greater omentum was released . the diaphragmatic defect seemed oval - shaped , and the edge of the aperture was smooth ( fig . 4 ) . there were no signs of necrosis or gastrointestinal perforation or other internal organ injuries . drainage of the right pleural cavity was placed in the thorax and the lung was expanded . the diaphragmatic defect during the operation chest x - ray performed on the 3 post operative day did not show any features of the diaphragmatic hernia . most posttraumatic diaphragmatic ruptures are located on the left side of the diaphragm and are the result of lower elasticity and vulnerability of this side , and also of the liver anatomy . right - sided diaphragmatic rupture is usually associated with massive injury ( 44 - 94% ) which results in liver , splenic and renal injuries and also pelvic and long bone fractures , large blood vessel injuries and head injuries . a congenital diaphragmatic defect is usually located in the left part of the muscle . only 5 - 10% of innate diaphragmatic defects are situated on the right side , and the symptoms are often atypical [ 68 ] . in our case the abdominal injury was mild , and it did not cause any specific internal organ injuries . the episode of stomachache and emesis a few months earlier might be a symptom of temporary herniation of the intestine into the congenital diaphragmatic defect . in the case of a patient with suspicion of posttraumatic diaphragmatic rupture , x - ray examination of the chest and abdomen , performed with a nasogastric tube , , the x - ray of the chest did not exclude the possibility of right - sided diaphragmatic rupture . only ct of the chest and abdomen enabled 3 dimensional reconstruction and appropriate assessment of anatomical structures . according to the literature , the main cause of delay in diagnosis of posttraumatic hernia is no sign of dislocation of abdominal organs into the chest in radiological examination . in the literature there are reports that in 8% of cases , the diagnosis of diaphragmatic rupture is missed from 18 days up to 15 years . an innate diaphragmatic defect , which could be the cause of the diaphragmatic hernia , might remain undiagnosed , as long as there is no herniation of the abdominal organs into the chest . in our case , the small innate defect of the diaphragm became a gateway for diaphragmatic herniation and the relatively mild injury caused dislocation of abdominal contents into the thorax with volvulus of the dislocated colon . the innate diaphragmatic defect in our patient could have remained asymptomatic and undiagnosed without the posttraumatic herniation of the abdominal organs into the chest and subsequent volvulus .
we present the case of a 13.5-year - old girl who was admitted to the pediatric surgery department from the pediatric department of a district hospital , where she stayed because of stomachache and vomiting . 
 interview revealed blunt injury of the epigastrium a week ago . 
 chest x - ray revealed a loss of the right diaphragmatic outline , irregular radiolucency on the right side of the chest , collapsed right lung and mediastinal displacement to the left . 
 the patient was operated on , and the surgery revealed herniation of the intestines and half of the stomach into the defect of the right dome of the diaphragm . 
 the patient made an uneventful postoperative recovery . 
 a small innate defect of the diaphragm can remain asymptomatic and undiagnosed as long as there is no herniation of the abdominal organs into the chest .