Abstract

Aim: Traumatic diaphragmatic rupture (TDR) is an uncommon injury in children and mostly encountered following major thoracoabdominal traumas. TDR diagnosis may not be recognized due to accompanying more severe injuries or absence of specific imaging signs and clinical symptoms may cause delayed diagnosis. In this article, we reported two children who presented with delayed diagnosis of diaphragmatic hernia, presumed to have TDR, and their clinical features were discussed to raise awareness relevant to TDR diagnosis.

Case 1: During imaging studies of a 9 year old boy complaining of vomiting, respiratory distress and feeding intolerance following an uneventful appendectomy procedure in another medical center was referred to our department for further evaluation due to irregular diaphragm outline demonstrated in the chest X-Ray. The patient had a medical history of falling a from height resulting in liver and spleen injury, 5 years ago. Contrast study of upper gastrointestinal tract revealed a left sided diaphragmatic hernia. During surgical intervention diaphragmatic defect was irregular, and presumed to be caused by trauma when considered with the medical history. The stomach herniating into the thorax was strangulated and had multiple perforations. The diaphragmatic defect and the perforations on the stomach were fixed with primary closures.

Case 2: A 14 year old boy complaining of non-specific abdominal pain was diagnosed with cholelithiasis. During his preoperative workup, chestX-ray demonstrated a left sided diaphragmatic hernia. Detailed medical history revealed that he had spleen injury and multiple bone fractures due to a traffic accident 6 months before. During surgical intervention diaphragmatic defect was irregular, and presumed to be caused by trauma when considered with the medical history. Primary closure of diaphragmatic defect and cholecystectomy were performed.

Conclusion: Initially TDR may be asymptomatic, and may become symptomatic as a result of pathologies that increase the abdominal pressure. However, existing symptoms are non-specific to the diagnosis. Thus, comparative evaluation of imaging studies in all children with thoracoabdominal trauma will facilitate early diagnosis and prevent potential complications.