What have we learned about traumatic diaphragmatic hernias in children?

BACKGROUND/PURPOSE: Diaphragmatic injuries have been reported to be a predictor of serious associated injuries in trauma and a marker of severity. The aim of this retrospective study was to identify pitfalls in the diagnosis and treatment of these injuries in children.

METHODS: Data were collected from all patients admitted to the trauma service with traumatic diaphragmatic hernias for the period of January 1977 to August 1998. The authors evaluated 15 cases of traumatic diaphragmatic rupture (6 girls and 9 boys).

RESULTS: Mean age was 7.5 years (range, 3 weeks to 15 years). Thirteen patients suffered from blunt trauma, and 2 patients suffered from penetrating trauma. The right and left hemidiaphragms were injured equally (7 patients each), with 1 additional patient suffering from bilateral injuries. All but 1 patient had laparotomies for trauma (n = 14). The diagnosis was made preoperatively in 8 patients (53%) with just a chest radiograph. Computed tomography (CT) scan, magnetic resonance imaging (MRI), and oral contrast studies were used as ancillary tests to diagnose traumatic diaphragmatic rupture. There were 3 missed injuries. Associated injuries included liver lacerations (47%), pelvic fractures (47%), major vessels tear (40%), bowel perforations (33%), long bone fractures (20%), renal lacerations (20%), splenic lacerations (13%), and closed head injuries (13%). The mean hospital stay was 20 days (range, 7 to 60 days). Complications were observed most commonly in those patients with multiple injuries and included postoperative ileus (40%), pneumonia (30%), pancreatitis (20%), wound infection (20%), intestinal obstruction (20%), cholestasis (10%), and renal failure (6%). Five deaths (33%) were caused by hemorrhagic shock, respiratory failure, coagulopathy, and refractory acidosis.

CONCLUSIONS: Traumatic diaphragmatic hernias usually are associated with serious injuries in children. It is important to combine a high index of suspicion with radiological diagnostic tests in patients at risk. Palpation and/or visualization of both diaphragms at laparotomy is extremely important in detecting these injuries when they are not suspected preoperatively.