What have we learned about traumatic diaphragmatic hernias in children?

Background/Purpose: Diaphragmatic injuries have been reported to be a predi ctor 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 servi ce with traumatic diaphragmatic hernias for the period of January 1977 to A ugust 1998. The authors evaluated 15 cases of traumatic diaphragmatic ruptu re (6 girls and 9 boys). Results: Mean age was 7.5 years (range, 3 weeks to 15 years). Thirteen pati ents suffered from blunt trauma, and 2 patients suffered from penetrating t rauma. The rig ht a nd left hemidiaphragms were injured equally (7 patients each), with 1 additional patient suffering from bilateral injuries. All bu t 1 patient had laparotomies for trauma (n = 14). The diagnosis was made pr eoperatively in 8 patients (53%) with just a chest radiograph. Computed tom ography (CT) scan, magnetic resonance imaging (MRI), and oral contrast stud ies were used as ancillary tests to diagnose traumatic diaphragmatic ruptur e, There were 3 missed injuries. Associated injuries included liver lacerat ions (47%), pelvic fractures (47%), major vessels tear (40%), bowel perfora tions (33%), long bone fractures (20%), renal lacerations (20%), splenic la cerations (13%), and closed head injuries (13%). The mean hospital stay was 20 days (range, 7 to 60 days). Complications were observed most commonly i n those patients with multiple injuries and included postoperative ileus (4 0%), 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 se rious injuries in children. It is important to combine a high index of susp icion with radiological diagnostic tests in patients at risk. Palpation and /or visualization of both diaphragms at laparotomy is extremely important i n detecting these injuries when they are not suspected preoperatively. Copy right (C) 2000 by W.B. Saunders Company.