Journal of Pediatric Surgery Case Reports 72 (2021) 101984

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Journal of Pediatric Surgery Case Reports

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Traumatic diaphragmatic hernia in children

B. Špaková a, b, *, M. Gura a, b, M. Molnár a, b, D. Murgaš a, b, M. Dragula a, b
a
Comenius University in Bratislava Jessenius Faculty of Medicine in Martin: Univerzita Komenského V Bratislave Jesseniova Lekárska Fakulta V Martine, Malá Hora 4A,
Martin, 03601, Slovakia
b
Pediatric Surgery Department, University Hospital Martin, Kollárova 2, Martin, 03601, Slovakia

A R T I C L E I N F O A B S T R A C T

Keywords: Traumatic diaphragmatic hernia is a relatively uncommon clinical entity, especially in children. It is often un­
Pediatric trauma diagnosed because of its rarity and coexistence with more obvious and serious injuries. Mortality of traumatic
Traumatic diaphragmatic rupture diaphragmatic rupture alone is rare, however delayed diagnosis may lead to higher mortality and morbidity rate.
Blunt abdominal trauma
Outcome is usually determined by concomitant injuries and complications. Usually a diaphragmatic injury oc­
curs in cases of blunt abdominal trauma (e.g. motor vehicle accidents) or penetrating trauma (e.g. gunshot or
stab injury). Iatrogenic causes are rare. It has three stages: 1. initial, 2. latent, and 3. obstructive. Clinical findings
vary depending on the stage of traumatic diaphragmatic injury. Subsequent complications, such as herniation or
strangulation of viscera may occur months or even years after primary injury. High index of suspicion of this
injury should be maintained when dealing with patients having respiratory or abdominal symptoms following
trauma of the thoracoabdominal region, and patients after high-velocity blunt abdominal or penetrating trauma.
We present two cases of traumatic diaphragmatic rupture and subsequent diaphragmatic hernia in pediatric
patients, admitted in our hospital 2 months apart in a row, with different clinical and radiological findings.

1. Introduction completely understood yet. However, there is a hypothesis that sudden

Traumatic diaphragmatic rupture (TDR) and traumatic diaphrag­
matic hernia (TDH) are relatively uncommon clinical entities, especially
in children. TDR occurs when the integrity of the diaphragm is violated
with the subsequent development of herniation of the abdominal organs
into the thoracic cavity. It is often undiagnosed or missed because of its
rarity, coexistence with more obvious and serious injuries, and hetero­
geneity in clinical presentation in the stage of bowel herniation [1,2].
Delayed diagnosis however may lead to higher mortality and morbidity
rate [2]. Injuries of diaphragm can be overseen, though overall inci­
dence is estimated to be higher than published [3].
The diaphragm is a musculotendinous double-domed shaped septum
separating thoracic from abdominal cavity [4]. It is the most important
respiratory muscle - during normal inspirium it decreases by 1–1.5cm,
because of contraction of muscle fibers, therefore the volume of thoracic
cavity is enlarged to provide 60 % of normal tidal volume [5]. As the
diaphragm is constantly moving during respiration, there is physiologic
fluctuation in pleuroperitoneal gradient (from +7 to +20 cm of H2O,
exceeding to +100 cm of H2O with maximal inspirium) [6,7]. The
pathophysiological mechanism in blunt diaphragmatic injury is not
increase in pleuroperitoneal gradient, by means of sudden increase in
intra-abdominal pressure, is associated with higher possibility of dia­
phragmatic disruption because of acute transfer of kinetic energy to the
diaphragm [6]. On the other hand, in penetrating trauma the mecha­
nism is a direct injury by dissection, e.g. stab and gunshot wounds [3]. In
case of a diaphragmatic injury, intra-abdominal organs can herniate
through the defect due to pleuroperitoneal gradient [2,6].
Traumatic rupture of diaphragm can be classified into three phases:
1. initial, 2. latent and 3. obstructive [8]. Initial or acute period lasts
from the accident itself to recovery from primary injuries (mostly in­
juries of liver, spleen, pelvis and kidneys [9]). During this period,
prompt management of serious concomitant injuries is indispensable,
and rupture of diaphragm may be unnoticed [8]. The duration of the
latent phase varies considerably, from hours and days till years. In the
study of Marzona et al. in the first 24 hours a diagnosis of TDR was
reached in 58.4 % of pediatric patients. During this latent phase patients
can be asymptomatic, or they can have vague gastrointestinal symptoms
because of intermittent obstruction of herniated organs, or cardiore­
spiratory symptoms due to mass effect of herniated viscera in thoracic
organs [8]. At the end of a latent period, herniated viscera become

* Corresponding author. Pediatric Surgery Department, University Hospital Martin, Kollárova 2, Martin, 03601, Slovakia.
E-mail addresses: barbora.spakova@gmail.com (B. Špaková), matejgura@gmail.com (M. Gura).

https://doi.org/10.1016/j.epsc.2021.101984
Received 1 July 2021; Received in revised form 22 July 2021; Accepted 24 July 2021
Available online 27 July 2021
2213-5766/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
B. Špaková et al.
obstructed, thus an obstructive phase can occur. The obstruction leads to
congestion, strangulation and if a condition is not recognized and
resolved promptly, necrosis and in some cases also rupture of necrotic
viscera may occur [3,8].
2. Case presentation
We present two cases of traumatic diaphragmatic hernias in our fa­
cility, which occurred just 2 months apart in a row. In the first case, we
discuss an 8 years old girl who was referred to our hospital with
symptoms of acute intestinal obstruction due to diaphragmatic hernia
which was unnoticed 2 years ago when she suffered multiple injuries
during a car accident. The second case is 18 years old participant in a
traffic accident, with multiple fractures of the facial skeleton, laceration
of the left side of a face, lungs contusion and supposed paresis of a left
diaphragm, which occurred to be TDR with subsequent herniation of
viscera into thoracic cavity.
2.1. Case 1
First case is about 8 years old female survivor of a car accident two
years ago, when she suffered severe blunt abdominal injury with
laceration of liver, right kidney and mesentery for which she underwent
emergency surgery. Signs of diaphragmatic rupture were not found
during the emergency surgery, nor on the chest and abdominal CT after
operation. For two years she was doing well, without any complications.
Later, she was admitted to hospital because of abdominal pain, vomitus
with intolerance of feeding, obstipation and history of one day old blunt
abdominal trauma – she was kicked in the abdomen by her younger
brother. After admission to the hospital an abdominal X-ray was done,
with a suspicion of right-sided diaphragmatic hernia. A thoracic and
abdominal CT scans revealed a massive diaphragmatic hernia on the
right side with a large bowel obstruction (Fig. 1). An emergency surgery
was scheduled immediately. In order to find a tear in the diaphragm, we
opted for a right subcostal incision. But, unfortunately, due to previous
abdominal trauma with multiple lacerations of liver, right kidney and
Fig. 1. X-ray and CT scan upon admission – X-ray showing visceral herniation into the right thoracic cavity with intestinal obstruction (left); CT scans (middle and
right respectively) showing herniation of right liver lobe with collar sign (star) and large bowel loops with mesentery through diaphragmatic defect (arrow).
2
Journal of Pediatric Surgery Case Reports 72 (2021) 101984
mesentery, the liver was completely adhered to the abdominal wall, thus
we had to perform a midline laparotomy, through the old scar. After
disruption of multiple adhesions of small bowels, we could see dilated
small bowel loops and ascendent colon, distal part of transverse colon
was completely empty. Through a diaphragmatic defect measuring 8 × 6
cm ascendent colon was entering to the right hemithorax. Diaphrag­
matic hernia contained the right lobe of liver and extremely dilated large
bowel, which was slowly repositioned inside the abdomen after
disruption of some adhesions. After disruption of adhesions of the liver
with abdominal wall and diaphragm, the liver was mobilized to the
abdomen and diaphragmatic defect was closed with nonabsorbable su­
tures (Ethibond 3/0). A chest tube was inserted and the abdominal wall
was closed in anatomic layers. Patient was left on mechanical ventila­
tion with complete relaxation during 3 postoperative days. Post­
operative X-rays were satisfactory (Fig. 2). Nasogastric tube gradually
drained a decreasing amount of content and on the 7th post-op day
feeding with clear fluids started, however it was stopped because of
transient intolerance till 15th post-op day. On the 21st post-op day a
patient was discharged from hospital and followed-up in our outpatient
clinic. One year after the operation the patient is fine without any
difficulties.
2.2. Case 2
In the second case we present an 18 years old male admitted to
hospital after a traffic accident. CT scans showed multiple fractures of
facial skeleton, chest X-ray showed left sided diaphragmatic elevation,
left lobe pulmonary contusion and traumatic paresis of stomach. He also
suffered cerebral commotion and laceration on the right side of face.
Repeated chest X-rays revealed persistent diaphragmatic paresis (Fig. 3).
7 days after the car accident he was referred to our hospital in order of
surgical reposition of facial fractures. During physical examination,
except for swelling of the face, breath sounds on the left side were
decreased, especially in the basal lung field, bowel sounds were heard
instead. Even though he did not complain of subjective respiratory
distress, nor the pain, he was without signs of gastrointestinal
B. Špaková et al.
Fig. 2. X-rays after operation – 1st postop day (left), 9th postop day (right).
obstruction. Preoperatively a chest CT was performed with the finding of
a diaphragmatic rupture with herniation of stomach and partial herni­
ation of large bowel into left pleural cavity (Fig. 4). The operation was
scheduled. During the first part of the operation a left sided thoracotomy
was performed. The stomach, omentum and a part of the large bowel
were found inside the pleural cavity. They were herniating through a
defect in the cupola of the diaphragm extending to the esophagus. The
length of the rupture was 8 cm. After reposition of herniated organs to
the abdominal cavity, the defect was closed with interrupted nonab­
sorbable suture (Surgilon 1/0). After left thoracic cavity lavage, a chest
tube was placed, and a thoracotomy was closed. The second part of the
operation was a maxilofacial procedure with reposition of facial skel­
eton fractures. The operation was performed without any complications.
Chest tube was extracted on the 3rd post-op day. Postoperative chest X-
rays were adequate (Fig. 5). Because of impaired breathing sounds in left
basal lung field and suspicion of incipient pneumonia, chest CT was
performed. There were found some atelectatic changes without signs of
bronchopneumonia. Patient was discharged on 10th post-op day in a
good clinical condition, 3 months after the operation he was without any
problems.
3. Discussion
Traumatic diaphragmatic injury is a rare type of trauma in child­
hood. According to Marzona et al. a prevalence of TDR in childhood
trauma is 0.07 %, when considering only blunt abdominal trauma it
increases to 2.95 % [9]. Although the incidence of TDH in children is
very low, it is more common than in the adult population [10]. This
paradox explains Rance et al. supposing that more elastic thoracic cage
and thinner abdominal wall in children can increase tendency to dia­
phragmatic injury which can result in herniation of viscera into the
thoracic cavity [2,11]. As traumatic diaphragmatic injury (TDI) is often
clinically occult, it can be difficult to find it out. Unnoticed TDI may
result in dangerous long-term sequelae by means of herniation of the
viscera into the thoracic cavity, resulting in respiratory problems and,
eventually strangulation of eviscerated organs, hence an accurate
diagnosis is really important [6].
We can distinguish between two types of traumatic injuries of dia­
phragm: 1. direct penetrating injuries, 2. indirect – blunt injuries to the
thoracoabdominal region traumatizing the diaphragm [8]. The main
3
Journal of Pediatric Surgery Case Reports 72 (2021) 101984
etiology of TDR is blunt abdominal trauma (BAT) because of a car ac­
cident, fall or crushing [9]. On the other side, penetrating trauma rep­
resents 13.5–55 % cases [12,13]. Although rarely, there was also
iatrogenic TDR, e.g. complication after chest tube insertion [14]. Most of
the traumatic diaphragmatic ruptures occur on the left side (57.9%) [9].
It is believed that the right hemidiaphragm is protected by the cush­
ioning effect of the liver, thus incidence of right-sided TDR is smaller
with 3:1 ratio [6]. However, some authors think that the incidence of
right-sided TDR is underestimated whereas it can be harder to diagnose
[15]. Predominant areas of TDR are the areas of embryonic weakness –
the dome and the posterior half of diaphragm [8].
Most symptoms of TDR include dyspnea (86%), abdominal pain
(13%), reduction in breath sounds on the affected side (73%) and
vomiting (13.4 %) [14]. Respiratory symptoms are usually seen in pe­
diatric and adult patients with clinically evident TDR after herniation of
abdominal organs into the thorax, due to the mass effect. They are
usually nonspecific in children, so they can be often related to associated
injuries. Normal oxygenation level and clear breathing sounds do not
rule out a possibility of TDR and diaphragmatic hernia, especially in case
of longer latent period when herniation can occur months or even years
after diaphragmatic injury [9]. On the other hand, however rare, the
presence of bowel sounds inside the thoracic cavity should be considered
as a pathognomonic sign of diaphragmatic herniation [9]. Abdominal
symptoms are the most frequent in adult patients, but very rare in
children with TDR [9]. Patients in the obstructive phase often complain
of typical signs of intestinal obstruction - obstipation, nausea, vomiting,
and abdominal distention [8]. The difference in degree of herniation of
bowels, leads to heterogeneity in clinical presentation [16], which can
contribute to delayed diagnosis as well as low incidence of this disease
[2].
To diagnose and effectively treat diaphragmatic rupture, a high
clinical index of suspicion is needed, especially in case of high velocity
accident (motor vehicle, traffic accidents), and/or evident injuries of
liver, spleen or fracture of pelvis [9]. Physicians should consider possible
diaphragmatic injury whenever there is a history of blunt
thoraco-abdominal or penetrating trauma with the development of
respiratory or abdominal symptoms. Especially in pediatric patients,
when there is a tendency to minimally invasive or non-surgical man­
agement of blunt abdominal injuries, which may result in more
frequently overseen TDR in this age group [9].
B. Špaková et al.
Fig. 3. X-rays after injury – X rays upon admission anteroposterior view (A), lateral view (B); 5 days after accident anteroposterior view during inspirium (C) and
expirium (D).
The first-line imaging study in case of TDR is a chest X-ray, it can
show pathognomonic or suspect findings in 85 % of cases [9]. The
second imaging study used in TDR is CT and other CT imaging tech­
niques (e.g. three-dimensional reconstruction), which usually confirms a
suspicion of traumatic diaphragmatic rupture [9]. Recently CT scans are
widely used in cases of polytraumatized patients, where it can help to
reveal the correct diagnosis with sensitivity almost 100 % [3]. Typical
findings on CT scans in case of TDR are usually visceral herniation
through the defect in diaphragm, direct visualization of the defect,
so-called “collar or hourglass sign” and partial disintegration of the
diaphragm [3,17,18].
Wounds of the diaphragm do not tend to heal spontaneously. The
laceration is often plugged by omentum or viscera, preventing acute
herniation, however this mechanism prevents a healing process [8].
Thus, TDR should be treated surgically. Preferred surgical approach for
acute TDR is laparotomy as most patients have other intra-abdominal
pathologies after BAT [19], as well as in cases of complications like
incarceration or strangulation of herniated viscera [3,20]. Thoracotomy
is chosen usually in case of chronic ruptures [14,21].
Mortality of TDR varies from 0 to 33 % mostly because of associated
injuries [9]. According to Marzona, vast majority (71,6 %) of patients
4
Journal of Pediatric Surgery Case Reports 72 (2021) 101984
with TDR have associated injuries, most frequently there are lesions of
liver (14,2 %), lungs (12,3 %), pelvis (10,35 %) and kidney (7,7 %) [9].
4. Conclusion
Traumatic diaphragmatic injury is a rare diagnosis in adult but also
pediatric patients. As it can be easily overseen, it is supposed that the
overall incidence is underestimated. Usually TDI can occur in cases of
blunt abdominal or penetrating trauma, iatrogenic cause is rather rare.
Trauma of the diaphragm may be direct (stab or gunshot wounds) or
indirect (blunt thoracoabdominal trauma in high energy acceleration-
deceleration mechanism). TDI has three stages: 1. initial, 2. latent, and
3. obstructive. Usually, more serious or life-threatening concomitant
injuries are found in polytrauma patients, though injury of diaphragm
may remain occult for various lengths of time. Subsequent complica­
tions, such as herniation or strangulation of viscera may occur months or
even years after primary injury. In the pediatric age group, the diagnosis
of TDR is more often delayed than in adult patients. It is probably caused
by the rarity of this diagnosis, but also by heterogeneity in clinical
presentation, as a function of the degree of visceral herniation. Treat­
ment is always surgical, as diaphragmatic injuries do not tend to heal
B. Špaková et al. Journal of Pediatric Surgery Case Reports 72 (2021) 101984

Fig. 4. CT scans before operation – herniation of stomach, a part of large bowel and omentum through diaphragmatic defect (arrow), collar sign (star).

Fig. 5. Postoperative chest X-rays – 1st day (left), 8th day (right).

spontaneously. Mortality of TDR alone is rare, outcome is usually Abbreviations

determined by concomitant injuries and complications.
Injury of diaphragm should be always considered in case of high- BAT blunt abdominal trauma
velocity BAT or penetrating trauma of the thoracoabdominal region, CT computer tomography
especially when liver, kidneys and/or spleen are injured. High index of TDH traumatic diaphragmatic hernia
suspicion of TDI should be maintained also when dealing with patients TDI traumatic diaphragmatic injury
having respiratory or abdominal symptoms and history of any kind of TDR traumatic diaphragmatic rupture
recent or older trauma of the thoracoabdominal region.
Patient consent
Declaration of competing interest
Consent to publish the case report was not obtained. This report does
The authors declare that they have no known competing financial not contain any personal information that could lead to the identifica­
interests or personal relationships that could have appeared to influence tion of the patient.
the work reported in this paper.
Funding
Acknowledgements
This research did not receive any specific grant from funding
None. agencies in the public, commercial, or not-for-profit sectors.

5
B. Špaková et al.
Authorship
All authors attest that they meet the current ICMJE criteria for
Authorship.
Financial disclosures
The following authors have no financial disclosures: Špaková B.,
Gura M., Molnár M., Murgaš D., Dragula M.
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