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Blunt traumatic diaphragmatic injuries in children
Injury, Int. J. Care Injured (2005) 36, 51—54
Blunt traumatic diaphragmatic injuries in children S.V.S. Soundappan, A.J.A. Holland*, D.T. Cass, G.B. Farrow Department of Academic Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia Accepted 2 November 2003
KEYWORDS Diaphragmatic injury; Blunt abdominal trauma; Paediatric
Summary Diaphragmatic injuries following blunt trauma are rare. From January 1988 to February 2002 eight children were treated at the Children’s Hospital at Westmead for diaphragmatic injury. Male to female ration was 5:3. Motor vehicle crashes were the most common cause. The injury was left-sided in four, right sided in three and central in one. Initial plain radiograph and computerised tomography detected the injury in 50% of cases. Laparotomy, contrast study and autopsy identified the rupture in one each. Associated injuries were present in all cases. Seven children had laparotomy and repair of the diaphragmatic rupture. The commonest site of rupture was posterolateral (37.5%). Diagnosis was delayed in two cases. There were two deaths (25% mortality) in the series, both due to associated injuries. Although rare, diaphragmatic rupture must be considered in any child with thoracoabdominal injury. Diagnosis may be difficult and require extensive investigation. Mortality usually results from associated injuries. ß 2004 Elsevier Ltd. All rights reserved.
Introduction Diaphragmatic injuries are rare occurring in about 3% of patients with blunt abdominal trauma (BAT).5 They are often missed due to difficulty in diagnosis compounded by the severity of other associated injury.5 Delayed diagnosis can lead to significant morbidity and even mortality.5,9 We report our experience in eight children with diaphragmatic injuries following blunt abdominal trauma.
2002. The records were identified from a search of the trauma databases at The Children’s Hospital at Westmead and Westmead Hospital. The medical records database at The Children’s Hospital was also interrogated. Both hospitals are Tertiary Trauma Centres treating over 1000 trauma patients a year. The case notes were studied for investigations results, time of diagnosis, side and site of injury, associated injuries, treatment and outcome.
Results Patients and methods A chart review of all patients admitted with the diagnosis of traumatic diaphragmatic injury was performed for the period January 1988 to February *Corresponding author. Tel.: þ61-2-9845-3059; fax: þ61-2-9845-3346. E-mail address: [email protected] (A.J.A. Holland).
There were eight patients (five boys and three girls) with diaphragmatic injuries following BAT. Age ranged from 3 to 13 years. Motor vehicle crash (MVC) was the cause in seven (five passengers and two pedestrians) and one child suffered a crush injury from a collapsed pillar. The left side was involved in four (50%), the right in three (37.5%) and there was a central rupture in one case (12.5%).
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.019
52
S.V.S. Soundappan et al.
Imaging Although all eight patients had a chest radiograph, diaphragmatic injury was diagnosed in only four cases using this modality (50%). All patients diagnosed on chest radiograph had a left-sided diaphragmatic injury revealed by the presence of herniated bowel loops or an absent diaphragmatic shadow. Six patients had abdominal computerised tomography (CT), but diaphragmatic injury was diagnosed in only three (50%), again all on the left side. All six had a chest radiograph as well but diaphragmatic injury was recognised in only three on both the investigations. In the remaining three patients both investigations missed the diagnosis, which was established at laparotomy in one, on autopsy in another and by a contrast study through an intercostal catheter in one.
ribs and renal contusion. His initial chest radiograph suggested an intact diaphragm. On Day 4 post-injury he developed abdominal pain and distension. A chest and abdominal radiograph revealed herniation of bowel into chest. The second patient was a 4-year-old girl involved in a MVC who was ventilated because of a severe head injury. She had a right-sided haemothorax, which was drained with an intercostal catheter. She had a persistently elevated right diaphragm associated with increasing ventilatory requirements. A diaphragmatic injury was suspected but CT, ultrasound and fluoroscopy were not diagnostic. A contrast study performed through her intercostal drain revealed contrast leaking into the peritoneal cavity. A right-sided diaphragmatic rupture was found at laparotomy and repaired.
Site of injury Timing of diagnosis Diaphragmatic injury was diagnosed early in four children based on investigation results, and in two children at laparotomy for haemodynamic instability.
The injury location is summarised in Table 1. The most frequent injury was a left-sided posterolateral tear (37.5%). All but one patient had their injury repaired operatively.
Diagnostic delay
Associated injuries
Diagnostic delay occurred in two cases. The first was a 9-year-old boy who was a passenger in a MVC. He was treated at a peripheral hospital for fractured
These were present in all patients (Table 1). Hepatic trauma was the commonest, occurring in four children (50%).
Table 1
Summary of the children with traumatic diaphragmatic hernia
No. Age (years)
Sex
Mechanism of injury
Side
Site of rupture
Diagnostic test
Associated injuries
Diagnostic delay
Result
1
13
M
Crush injury
Right
Posterolateral
Laparotomy
None
Survived
2
9
M
MVC-passenger
Left
Posterolateral
CXR
4 days
Survived
3
10
F
MVC-passenger
Left
Hiatus, crus & dome
CXR,CT
None
Survived
4 5 6
3 6 5
F M M
MVC-pedestrian Central MVC-pedestrian Left MVC-passenger Right
Caval hiatus Lateral tear Posterolateral
Laparotomy CXR, CT Autopsy
None None None
Died Survived Died
7
4
F
MVC-passenger
Right
Peripheral avulsion
Contrast study
11 days
Survived
8
11
M
MVC-passenger
Left
Peripheral tear
CXR, CT
#Ribs, #scapula, pneumothorax, #pelvis & acetabulum, liver laceration Renal contusion, #10th and 11th ribs #Shoulder, lung contusion, liver laceration, mesenteric & retroperitoneal haematoma Hepatic vein transection #Pelvis, liver laceration Hepatic vein and IVC tear, SAH, C1 dislocation, haemothorax, lung contusion, scalp laceration SDH, hemothorax, lung contusion right, #right ulna Laceration liver, #ribs, #clavicle left
None
Survived
SAH: subarachnoid haemorrhage, SDH: subdural haemorrhage.
Blunt traumatic diaphragmatic injuries in children
Mortality There were two deaths in our series (25%). One resulted from hypovolaemic shock due to a venacaval injury. The other child also died with a caval injury but had an associated C1 dislocation and brainstem injury. The site of rupture was at the caval hiatus in the first and right dome of diaphragm in the second.
Discussion Diaphragmatic injury following blunt trauma remains rare in children and may be more difficult to assess than in adults for both anatomical and physiological reasons.5 The compliance of the paediatric chest wall may result in internal injury in the absence of external evidence of major injury.5 The mediastinum of a child is more mobile and readily compromised by haemothorax, pneumothorax or herniated abdominal contents than in an adult. The pathophysiology of blunt diaphragmatic trauma is poorly understood but the most attractive explanation remains that the transmission of force through the abdominal viscera to the diaphragm results in the rupture.6 As minor injuries have caused rupture of diaphragm, the timing of impact during the respiratory cycle is possibly more important than the severity of trauma, creating a significant pressure gradient across the diaphragm.6
Clinical presentation Acute injuries may be asymptomatic or present with chest pain, abdominal pain, respiratory distress or shock. Physical examination is rarely specific in the multitrauma scenario. Difficulty in passing the nasogastric tube is said to be suggestive of diaphragmatic injury as herniation of stomach into chest increases the acuity of the gastroesophageal angle, but this was not a feature of our paediatric series.
Radiological diagnosis Diagnostic features are well described on plain chest radiography but, as shown in this series, this investigation may be normal in up to 50% of the cases.5,7,9,13,14 Initial chest radiography may be normal, but repeat radiographs may demonstrate diagnostic findings,7 as was seen in one of our patients who was diagnosed 4 days after his injury. Intubation and positive pressure ventilation could reduce a diaphragmatic hernia and a chest radiograph or CT may then appear normal.14 Helical CT has been reported to have good sensitivity and specificity in
53 adults.2,10 This was not a finding of this paediatric series. CT appears unreliable for lateral tears, where the diaphragm merges with the liver and spleen, in the absence of fluid in the abdomen or herniation.9,14 Bergin et al.2 described a new sign called the dependant viscera sign in a series of adult patients with blunt traumatic diaphragmatic rupture where the upper one third of liver on right or stomach or bowel on the left side lay in contact with posterior ribs. This sign had a reported 100% sensitivity for left-sided diaphragmatic injuries and 83% sensitivity for right-sided injuries. None of our patients had the dependent viscera sign reported on their CT scan. Use of magnetic resonance imaging (MRI) for the diagnosis of diaphragmatic injuries in the acute setting is limited due to monitoring difficulties, a potentially unstable patient, the need for general anaesthesia in children and the length of examination.3,9 MRI has been diagnostic in the presence of equivocal chest radiographs or CT scans.3,4,7,9,12 Ultrasound could be useful to diagnose diaphragmatic injury in the unstable patient who cannot be taken to the radiology department.1 Fluoroscopy9,15 and contrast studies9,16 have been useful with delayed presentations or when other investigations are not diagnostic.
Side of injury The incidence of right-sided injuries (37.5%) in our series was much higher than the 12—20% previously reported.4,9 The bias to the left side presumably reflects the protective effect of liver on the right, and possible under diagnosis of right-sided ruptures. Koplewitz et al.9 suggested that right side injuries might be more common in children because of the relatively flexible suspensory ligament of the liver offering less protection to the right hemidiaphragm. Chest radiography rarely diagnoses right-sided injuries7 as illustrated in our patients. Right-sided injuries have been associated with a lateral impact4 in adult series of left hand driven vehicles. Right side injuries are associated with greater prehospital mortality and often require urgent surgical intervention, due to severe associated injury.4 Rightsided injuries were associated with higher mortality in our series.
Site of injury The commonest site of rupture was radial and posterolateral,4 representing the site of embryonic weakness from the pleuroperitoneal membrane. Two patients in our series had a central injury, although in one this was an extension of a tear in the left dome.
54
S.V.S. Soundappan et al.
Associated injuries
Acknowledgements
Associated injuries were present in all our cases, supporting a reported incidence in the literature between 75 and 100%.5,10,12 Associated intraabdominal injuries are present in 80—90%.4 Liver injury was the commonest associated injury in our series (50%). Two children who died of their injuries had caval or hepatic vein trauma. Liver, hepatic vein or IVC injury has been reported in 33—66% of cases.10 Brandt et al.5 cited a 10% incidence of associated thoracic arterial or venous injuries that are fatal.
We thank Dr. Valeri Malka, Director of Trauma, for permission to use the trauma database at Westmead Hospital, and Ms. Linda Gutierrez, Secretary, Department of Trauma, Westmead Hospital for assistance with acquiring data from the Westmead Hospital trauma database.
Surgical repair Open surgical repair has been the traditional method of treating blunt traumatic diaphragmatic injuries. Mesh or prosthetic repair is rarely needed in the acute stage but may be useful for a delayed repair. With the advent of laparoscopy for abdominal surgery there is renewed interest in the role of laparoscopy in abdominal trauma. Laparoscopy may be an especially useful tool for diagnosis of diaphragmatic injury in the delayed setting, facilitating a magnified image of the whole diaphragm.11 The presence of dilated bowel, dangers of positive pressure and low sensitivity of laparoscopy for other injuries like small bowel and retroperitoneal injuries limits its use in the acute setting and there are a few reports of successful laparoscopic repair of diaphragmatic injuries.8,11
Mortality The mortality rate in our series was 25%, which corresponds to the reported mortality rate of 20— 50% in both adult and paediatric series.4,5
Conclusions Diaphragmatic injuries in children were rare. Highspeed MVCs represent the commonest mechanism of injury. Initial chest radiograph and CT scan were diagnostic in half of our patients. The diagnosis may be difficult and require extensive investigation. Right-sided injury appears to be more common in children. Laparoscopy may represent a useful technique when standard diagnostic methods fail to reveal a diaphragmatic rupture. Blunt traumatic diaphragmatic injury in isolation rarely causes death but is a marker for severe injury.
References 1. Amman AM, Brewer WH, Maull KI, Walsh JW. Traumatic rupture of the diaphragm: real time sonographic diagnosis. Am J Roentgenol 1983;140:915—6. 2. Bergin D, Ennis R, Keogh C, Fenlon AM, Murray JG. The dependent viscera sign in CT diagnosis of blunt traumatic diaphragmatic rupture. Am J Roentgenol 2001;177:1137—40. 3. Boulanger BR, Stuart ME, Rodriguez A. Magnetic resonance imaging in traumatic diaphragmatic rupture: case reports. J Trauma 1992;32:89—93. 4. Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left traumatic diaphragmatic rupture. J Trauma 1993;35:255—60. 5. Brandt ML, Luks FI, Spigland NA, O’Ilorenzo M, Laberge J, Ouimet A. Diaphragmatic injury in children. J Trauma 1992; 32:298—300. 6. Estera AS, Platt MR, Mills LJ. Traumatic Injuries of the diaphragm. Chest 1979;75:306—13. 7. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma. Am J Roentgenol 1991;156:51—7. 8. Huttl TP, Lang R, Meyer G. Long term results after laparoscopic repair of traumatic diaphragmatic hernias. J Trauma 2002;52:562—5. 9. Koplewitz BZ, Ramos C, Manson DE, Babyn PS, Ein SH. Traumatic diaphragmatic injuries in infants and children: Imaging findings. Eur Rad 2000;30:471—9. 10. Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR, Gotway CA, et al. Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. Am J Roentgenol 2002;179:451—7. 11. Lindsey I, Woods SDS, Nottle PD. Laparoscopic management of blunt diaphragmatic injury. Aust N Z J Surg 1997;67: 619—21. 12. Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia occult marker of serious injury. Ann Surg 1993;218:783—90. 13. Murray JG, Caoili E, Grunden JF, Evans SJJ, Halvorsen RA, Mackersie RC. Acute rupture of diaphragm due to blunt trauma. Diagnostic sensitivity and specificity of CT. Am J Roentgenol 1996;166:1035—9. 14. Shapiro MJ, Heiberg E, Durham RM. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996; 51:27—30. 15. Sharma AK, Kothari SK, Gupta C, Menon P, Sharma A. Rupture of right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma. Paediatr Surg Int 2002;18: 173—4. 16. Wheatley JM, Cohen RC, Steinberg A. Right side diaphragmatic hernia a simple technique for diagnosis. Paediatr Surg Int 1993;8:427—8.
Blunt traumatic diaphragmatic injuries in children S.V.S. Soundappan, A.J.A. Holland*, D.T. Cass, G.B. Farrow Department of Academic Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked Bag 4001, Westmead, NSW 2145, Australia Accepted 2 November 2003
KEYWORDS Diaphragmatic injury; Blunt abdominal trauma; Paediatric
Summary Diaphragmatic injuries following blunt trauma are rare. From January 1988 to February 2002 eight children were treated at the Children’s Hospital at Westmead for diaphragmatic injury. Male to female ration was 5:3. Motor vehicle crashes were the most common cause. The injury was left-sided in four, right sided in three and central in one. Initial plain radiograph and computerised tomography detected the injury in 50% of cases. Laparotomy, contrast study and autopsy identified the rupture in one each. Associated injuries were present in all cases. Seven children had laparotomy and repair of the diaphragmatic rupture. The commonest site of rupture was posterolateral (37.5%). Diagnosis was delayed in two cases. There were two deaths (25% mortality) in the series, both due to associated injuries. Although rare, diaphragmatic rupture must be considered in any child with thoracoabdominal injury. Diagnosis may be difficult and require extensive investigation. Mortality usually results from associated injuries. ß 2004 Elsevier Ltd. All rights reserved.
Introduction Diaphragmatic injuries are rare occurring in about 3% of patients with blunt abdominal trauma (BAT).5 They are often missed due to difficulty in diagnosis compounded by the severity of other associated injury.5 Delayed diagnosis can lead to significant morbidity and even mortality.5,9 We report our experience in eight children with diaphragmatic injuries following blunt abdominal trauma.
2002. The records were identified from a search of the trauma databases at The Children’s Hospital at Westmead and Westmead Hospital. The medical records database at The Children’s Hospital was also interrogated. Both hospitals are Tertiary Trauma Centres treating over 1000 trauma patients a year. The case notes were studied for investigations results, time of diagnosis, side and site of injury, associated injuries, treatment and outcome.
Results Patients and methods A chart review of all patients admitted with the diagnosis of traumatic diaphragmatic injury was performed for the period January 1988 to February *Corresponding author. Tel.: þ61-2-9845-3059; fax: þ61-2-9845-3346. E-mail address: [email protected] (A.J.A. Holland).
There were eight patients (five boys and three girls) with diaphragmatic injuries following BAT. Age ranged from 3 to 13 years. Motor vehicle crash (MVC) was the cause in seven (five passengers and two pedestrians) and one child suffered a crush injury from a collapsed pillar. The left side was involved in four (50%), the right in three (37.5%) and there was a central rupture in one case (12.5%).
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.11.019
52
S.V.S. Soundappan et al.
Imaging Although all eight patients had a chest radiograph, diaphragmatic injury was diagnosed in only four cases using this modality (50%). All patients diagnosed on chest radiograph had a left-sided diaphragmatic injury revealed by the presence of herniated bowel loops or an absent diaphragmatic shadow. Six patients had abdominal computerised tomography (CT), but diaphragmatic injury was diagnosed in only three (50%), again all on the left side. All six had a chest radiograph as well but diaphragmatic injury was recognised in only three on both the investigations. In the remaining three patients both investigations missed the diagnosis, which was established at laparotomy in one, on autopsy in another and by a contrast study through an intercostal catheter in one.
ribs and renal contusion. His initial chest radiograph suggested an intact diaphragm. On Day 4 post-injury he developed abdominal pain and distension. A chest and abdominal radiograph revealed herniation of bowel into chest. The second patient was a 4-year-old girl involved in a MVC who was ventilated because of a severe head injury. She had a right-sided haemothorax, which was drained with an intercostal catheter. She had a persistently elevated right diaphragm associated with increasing ventilatory requirements. A diaphragmatic injury was suspected but CT, ultrasound and fluoroscopy were not diagnostic. A contrast study performed through her intercostal drain revealed contrast leaking into the peritoneal cavity. A right-sided diaphragmatic rupture was found at laparotomy and repaired.
Site of injury Timing of diagnosis Diaphragmatic injury was diagnosed early in four children based on investigation results, and in two children at laparotomy for haemodynamic instability.
The injury location is summarised in Table 1. The most frequent injury was a left-sided posterolateral tear (37.5%). All but one patient had their injury repaired operatively.
Diagnostic delay
Associated injuries
Diagnostic delay occurred in two cases. The first was a 9-year-old boy who was a passenger in a MVC. He was treated at a peripheral hospital for fractured
These were present in all patients (Table 1). Hepatic trauma was the commonest, occurring in four children (50%).
Table 1
Summary of the children with traumatic diaphragmatic hernia
No. Age (years)
Sex
Mechanism of injury
Side
Site of rupture
Diagnostic test
Associated injuries
Diagnostic delay
Result
1
13
M
Crush injury
Right
Posterolateral
Laparotomy
None
Survived
2
9
M
MVC-passenger
Left
Posterolateral
CXR
4 days
Survived
3
10
F
MVC-passenger
Left
Hiatus, crus & dome
CXR,CT
None
Survived
4 5 6
3 6 5
F M M
MVC-pedestrian Central MVC-pedestrian Left MVC-passenger Right
Caval hiatus Lateral tear Posterolateral
Laparotomy CXR, CT Autopsy
None None None
Died Survived Died
7
4
F
MVC-passenger
Right
Peripheral avulsion
Contrast study
11 days
Survived
8
11
M
MVC-passenger
Left
Peripheral tear
CXR, CT
#Ribs, #scapula, pneumothorax, #pelvis & acetabulum, liver laceration Renal contusion, #10th and 11th ribs #Shoulder, lung contusion, liver laceration, mesenteric & retroperitoneal haematoma Hepatic vein transection #Pelvis, liver laceration Hepatic vein and IVC tear, SAH, C1 dislocation, haemothorax, lung contusion, scalp laceration SDH, hemothorax, lung contusion right, #right ulna Laceration liver, #ribs, #clavicle left
None
Survived
SAH: subarachnoid haemorrhage, SDH: subdural haemorrhage.
Blunt traumatic diaphragmatic injuries in children
Mortality There were two deaths in our series (25%). One resulted from hypovolaemic shock due to a venacaval injury. The other child also died with a caval injury but had an associated C1 dislocation and brainstem injury. The site of rupture was at the caval hiatus in the first and right dome of diaphragm in the second.
Discussion Diaphragmatic injury following blunt trauma remains rare in children and may be more difficult to assess than in adults for both anatomical and physiological reasons.5 The compliance of the paediatric chest wall may result in internal injury in the absence of external evidence of major injury.5 The mediastinum of a child is more mobile and readily compromised by haemothorax, pneumothorax or herniated abdominal contents than in an adult. The pathophysiology of blunt diaphragmatic trauma is poorly understood but the most attractive explanation remains that the transmission of force through the abdominal viscera to the diaphragm results in the rupture.6 As minor injuries have caused rupture of diaphragm, the timing of impact during the respiratory cycle is possibly more important than the severity of trauma, creating a significant pressure gradient across the diaphragm.6
Clinical presentation Acute injuries may be asymptomatic or present with chest pain, abdominal pain, respiratory distress or shock. Physical examination is rarely specific in the multitrauma scenario. Difficulty in passing the nasogastric tube is said to be suggestive of diaphragmatic injury as herniation of stomach into chest increases the acuity of the gastroesophageal angle, but this was not a feature of our paediatric series.
Radiological diagnosis Diagnostic features are well described on plain chest radiography but, as shown in this series, this investigation may be normal in up to 50% of the cases.5,7,9,13,14 Initial chest radiography may be normal, but repeat radiographs may demonstrate diagnostic findings,7 as was seen in one of our patients who was diagnosed 4 days after his injury. Intubation and positive pressure ventilation could reduce a diaphragmatic hernia and a chest radiograph or CT may then appear normal.14 Helical CT has been reported to have good sensitivity and specificity in
53 adults.2,10 This was not a finding of this paediatric series. CT appears unreliable for lateral tears, where the diaphragm merges with the liver and spleen, in the absence of fluid in the abdomen or herniation.9,14 Bergin et al.2 described a new sign called the dependant viscera sign in a series of adult patients with blunt traumatic diaphragmatic rupture where the upper one third of liver on right or stomach or bowel on the left side lay in contact with posterior ribs. This sign had a reported 100% sensitivity for left-sided diaphragmatic injuries and 83% sensitivity for right-sided injuries. None of our patients had the dependent viscera sign reported on their CT scan. Use of magnetic resonance imaging (MRI) for the diagnosis of diaphragmatic injuries in the acute setting is limited due to monitoring difficulties, a potentially unstable patient, the need for general anaesthesia in children and the length of examination.3,9 MRI has been diagnostic in the presence of equivocal chest radiographs or CT scans.3,4,7,9,12 Ultrasound could be useful to diagnose diaphragmatic injury in the unstable patient who cannot be taken to the radiology department.1 Fluoroscopy9,15 and contrast studies9,16 have been useful with delayed presentations or when other investigations are not diagnostic.
Side of injury The incidence of right-sided injuries (37.5%) in our series was much higher than the 12—20% previously reported.4,9 The bias to the left side presumably reflects the protective effect of liver on the right, and possible under diagnosis of right-sided ruptures. Koplewitz et al.9 suggested that right side injuries might be more common in children because of the relatively flexible suspensory ligament of the liver offering less protection to the right hemidiaphragm. Chest radiography rarely diagnoses right-sided injuries7 as illustrated in our patients. Right-sided injuries have been associated with a lateral impact4 in adult series of left hand driven vehicles. Right side injuries are associated with greater prehospital mortality and often require urgent surgical intervention, due to severe associated injury.4 Rightsided injuries were associated with higher mortality in our series.
Site of injury The commonest site of rupture was radial and posterolateral,4 representing the site of embryonic weakness from the pleuroperitoneal membrane. Two patients in our series had a central injury, although in one this was an extension of a tear in the left dome.
54
S.V.S. Soundappan et al.
Associated injuries
Acknowledgements
Associated injuries were present in all our cases, supporting a reported incidence in the literature between 75 and 100%.5,10,12 Associated intraabdominal injuries are present in 80—90%.4 Liver injury was the commonest associated injury in our series (50%). Two children who died of their injuries had caval or hepatic vein trauma. Liver, hepatic vein or IVC injury has been reported in 33—66% of cases.10 Brandt et al.5 cited a 10% incidence of associated thoracic arterial or venous injuries that are fatal.
We thank Dr. Valeri Malka, Director of Trauma, for permission to use the trauma database at Westmead Hospital, and Ms. Linda Gutierrez, Secretary, Department of Trauma, Westmead Hospital for assistance with acquiring data from the Westmead Hospital trauma database.
Surgical repair Open surgical repair has been the traditional method of treating blunt traumatic diaphragmatic injuries. Mesh or prosthetic repair is rarely needed in the acute stage but may be useful for a delayed repair. With the advent of laparoscopy for abdominal surgery there is renewed interest in the role of laparoscopy in abdominal trauma. Laparoscopy may be an especially useful tool for diagnosis of diaphragmatic injury in the delayed setting, facilitating a magnified image of the whole diaphragm.11 The presence of dilated bowel, dangers of positive pressure and low sensitivity of laparoscopy for other injuries like small bowel and retroperitoneal injuries limits its use in the acute setting and there are a few reports of successful laparoscopic repair of diaphragmatic injuries.8,11
Mortality The mortality rate in our series was 25%, which corresponds to the reported mortality rate of 20— 50% in both adult and paediatric series.4,5
Conclusions Diaphragmatic injuries in children were rare. Highspeed MVCs represent the commonest mechanism of injury. Initial chest radiograph and CT scan were diagnostic in half of our patients. The diagnosis may be difficult and require extensive investigation. Right-sided injury appears to be more common in children. Laparoscopy may represent a useful technique when standard diagnostic methods fail to reveal a diaphragmatic rupture. Blunt traumatic diaphragmatic injury in isolation rarely causes death but is a marker for severe injury.
References 1. Amman AM, Brewer WH, Maull KI, Walsh JW. Traumatic rupture of the diaphragm: real time sonographic diagnosis. Am J Roentgenol 1983;140:915—6. 2. Bergin D, Ennis R, Keogh C, Fenlon AM, Murray JG. The dependent viscera sign in CT diagnosis of blunt traumatic diaphragmatic rupture. Am J Roentgenol 2001;177:1137—40. 3. Boulanger BR, Stuart ME, Rodriguez A. Magnetic resonance imaging in traumatic diaphragmatic rupture: case reports. J Trauma 1992;32:89—93. 4. Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left traumatic diaphragmatic rupture. J Trauma 1993;35:255—60. 5. Brandt ML, Luks FI, Spigland NA, O’Ilorenzo M, Laberge J, Ouimet A. Diaphragmatic injury in children. J Trauma 1992; 32:298—300. 6. Estera AS, Platt MR, Mills LJ. Traumatic Injuries of the diaphragm. Chest 1979;75:306—13. 7. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma. Am J Roentgenol 1991;156:51—7. 8. Huttl TP, Lang R, Meyer G. Long term results after laparoscopic repair of traumatic diaphragmatic hernias. J Trauma 2002;52:562—5. 9. Koplewitz BZ, Ramos C, Manson DE, Babyn PS, Ein SH. Traumatic diaphragmatic injuries in infants and children: Imaging findings. Eur Rad 2000;30:471—9. 10. Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR, Gotway CA, et al. Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. Am J Roentgenol 2002;179:451—7. 11. Lindsey I, Woods SDS, Nottle PD. Laparoscopic management of blunt diaphragmatic injury. Aust N Z J Surg 1997;67: 619—21. 12. Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia occult marker of serious injury. Ann Surg 1993;218:783—90. 13. Murray JG, Caoili E, Grunden JF, Evans SJJ, Halvorsen RA, Mackersie RC. Acute rupture of diaphragm due to blunt trauma. Diagnostic sensitivity and specificity of CT. Am J Roentgenol 1996;166:1035—9. 14. Shapiro MJ, Heiberg E, Durham RM. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996; 51:27—30. 15. Sharma AK, Kothari SK, Gupta C, Menon P, Sharma A. Rupture of right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma. Paediatr Surg Int 2002;18: 173—4. 16. Wheatley JM, Cohen RC, Steinberg A. Right side diaphragmatic hernia a simple technique for diagnosis. Paediatr Surg Int 1993;8:427—8.