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What have we learned about traumatic diaphragmatic hernias in children?
C T Ramos1, B Z Koplewitz, P S Babyn
1Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Pediatric diaphragmatic rupture often indicates severe associated injuries. Early suspicion and diagnostic imaging, alongside intraoperative examination, are crucial for accurate diagnosis and improved outcomes in pediatric trauma patients.
Area of Science:
- Pediatric Trauma Surgery
- Thoracic Surgery
- Diagnostic Imaging in Pediatrics
Background:
- Diaphragmatic injuries in children are associated with significant trauma severity.
- These injuries serve as critical indicators of associated life-threatening conditions.
Purpose of the Study:
- To identify diagnostic and therapeutic challenges in pediatric traumatic diaphragmatic injuries.
- To analyze pitfalls in managing diaphragmatic rupture in pediatric trauma cases.
Main Methods:
- Retrospective analysis of 15 pediatric patients with traumatic diaphragmatic rupture (1977-1998).
- Inclusion criteria: patients admitted to trauma service with diaphragmatic hernias.
- Data collection included patient demographics, trauma type, diagnostic methods, associated injuries, and outcomes.
Main Results:
- Mean age 7.5 years; 13 blunt, 2 penetrating trauma.
- 53% diagnosed preoperatively via chest radiograph; 3 injuries missed.
- High rates of associated injuries (liver, pelvic, vascular, bowel) and complications (ileus, pneumonia, infection).
Conclusions:
- Traumatic diaphragmatic hernias in children frequently accompany severe injuries.
- A high index of suspicion combined with diagnostic imaging is essential.
- Intraoperative palpation/visualization of diaphragms is vital for missed injuries.
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.