Traumatic diaphragmatic hernia in childhood

Abstract

Approximately 10% of blunt traumatic injuries in children involved the thorax. Among these cases, traumatic diaphragmatic hernia is a relatively uncommon injury. This report describes the clinical findings and supportive and operative management in four children with traumatic diaphragmatic hernia. The hernia was on the right side in 2 patients, the left side in 1, and was bilateral in 1. There were 2 boys and 2 girls, ages 11 mo, 3.5 yr, 4.5 yr, and 6 yr. Trauma was related to vehicular-pedestrian (3) and passenger (1) injuries. Despite the fact that chest x-ray was diagnostic or highly suspicious, delay in diagnosis was observed in 2 patients (3 days, 3 mo) initially managed elsewhere. Acute respiratory distress was observed in 2 patients (pneumothorax, bilateral diaphragmatic hernias); however, all four had hypoxemia (pO2<70 mm Torr). Ventilator support was required in three patients because of associated pulmonary contusion. All four patients were explored by the trans-abdominal route. Following reduction of viscera (liver on right (3), stomach and colon on left (2)), chest tubes were inserted and primary diaphragmatic hernia repair accomplished with interrupted 3–0 or 2–0 mattress sutures. In addition, liver and splenic lacerations were repaired in two cases. All four patients survived. Although previous reports suggest right sided traumatic diaphragmatic hernias are unusual, three of our patients in this report had right sided defects. Diaphragmatic hernia should be suspected in children with blunt lower thoracic cage injury. Transabdominal repair is useful in (1) repairing the defect, (2) managing associated intra-abdominal injuries, and (3) recognizing instances of bilateral diaphragmatic injury. Approximately 10% of blunt traumatic injuries in children involved the thorax. Among these cases, traumatic diaphragmatic hernia is a relatively uncommon injury. This report describes the clinical findings and supportive and operative management in four children with traumatic diaphragmatic hernia. The hernia was on the right side in 2 patients, the left side in 1, and was bilateral in 1. There were 2 boys and 2 girls, ages 11 mo, 3.5 yr, 4.5 yr, and 6 yr. Trauma was related to vehicular-pedestrian (3) and passenger (1) injuries. Despite the fact that chest x-ray was diagnostic or highly suspicious, delay in diagnosis was observed in 2 patients (3 days, 3 mo) initially managed elsewhere. Acute respiratory distress was observed in 2 patients (pneumothorax, bilateral diaphragmatic hernias); however, all four had hypoxemia (pO2<70 mm Torr). Ventilator support was required in three patients because of associated pulmonary contusion. All four patients were explored by the trans-abdominal route. Following reduction of viscera (liver on right (3), stomach and colon on left (2)), chest tubes were inserted and primary diaphragmatic hernia repair accomplished with interrupted 3–0 or 2–0 mattress sutures. In addition, liver and splenic lacerations were repaired in two cases. All four patients survived. Although previous reports suggest right sided traumatic diaphragmatic hernias are unusual, three of our patients in this report had right sided defects. Diaphragmatic hernia should be suspected in children with blunt lower thoracic cage injury. Transabdominal repair is useful in (1) repairing the defect, (2) managing associated intra-abdominal injuries, and (3) recognizing instances of bilateral diaphragmatic injury.