Journal of Pediatric Surgery 49 (2014) 420–423

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Journal of Pediatric Surgery

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Traumatic diaphragmatic rupture in children

Mehmet Hanifi Okur a,⁎, Ibrahim Uygun a, Mehmet Serif Arslan a, Bahattin Aydogdu a, Ahmet Turkoglu d,
Cemil Goya b, Mustafa Icen c, Murat Kemal Cigdem a, Abdurrahman Onen a, Selcuk Otcu a
a
Dicle University Faculty of Medicine, Department of Pediatric Surgery, 21280, Diyarbakir, Turkey
b
Dicle University Faculty of Medicine Department of Radiology, 21280, Diyarbakir, Turkey
c
Dicle University Faculty of Medicine, Department of Emergency Medicine, 21280, Diyarbakir, Turkey
d
Dicle University Faculty of Medicine, Department of General Surgery, 21280, Diyarbakir, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Background: The purpose of this study was to describe our experience with traumatic diaphragmatic rupture
Received 20 February 2013 (TDR). Very little has been written about this condition in the pediatric age group.
Received in revised form 6 November 2013 Methods: Between January 2000 and December 2011, data on twenty-two patients with TDR were analyzed,
Accepted 12 November 2013 and clinical data were recorded. The patients were divided into subgroups based on injury type and ISS values.
Results: Four patients were female, and eighteen were male. Mean age was 9.4 years (range 2–15 years). TDR
Key words:
was left-sided in twenty (91%) patients and right-sided in two (9%). The mean ISS (Injury Severity Score) was
Children
Thoracoabdominal trauma
19 (range 11–29). No significant difference in morbidity was noted between firearm and other injuries (p =
Diaphragm rupture 0.565) or between ISS values below and above 16 (p = 0.565). Seven patients (32%) had isolated
diaphragmatic injury, while the other fifteen cases had additional associated injuries. Diagnoses were
determined via a chest radiograph alone in the majority of cases, while suspected cases were confirmed by
multidetector computed tomography if the patients were hemodynamically stable. Herniation was observed
in twenty patients. Primary suture of the diaphragm and tube thoracostomy were performed in all patients.
Postoperative complications included ileus (two cases), intussusception (one case), empyema (one case), and
one patient succumbed during the operation.
Conclusions: TDR, while uncommon, should be considered in cases of thoracoabdominal injury. All patients
should undergo meticulous examination preoperatively. When the chest radiograph does not provide a
definitive diagnosis, multidetector computed tomography, including multiplanar reconstruction or volume
rendering, may be beneficial for confirming suspicion of diaphragmatic rupture.
© 2014 Elsevier Inc. All rights reserved.

Traumatic diaphragmatic rupture (TDR) usually results from blunt
or penetrating injuries, and is rarely iatrogenic. Although several adult
series have examined TDR, very little concerning TDR in the pediatric
age group has been published [1–4]. TDR is associated with other
severe injuries in 44%–94% of cases [5–7]. The severity of these
associated injuries can be assessed via the Injury Severity Score (ISS).
Chest radiograph (CXR) and multidetector computed tomography
(MDCT) are most commonly used to achieve the diagnosis. TDR can be
overlooked if it is unsuspected, with nonspecific clinical and
radiological findings. Timely diagnosis requires a high degree of
suspicion. Delayed diagnosis may lead to prolonged intestinal
herniation, resulting in obstruction, ischemia, sepsis, and death.
Diaphragmatic repair can be performed using laparotomy, thoracot-
omy, or both laparotomy and thoracotomy. On review of the
literature, few large pediatric series of TDR were found. The current
study describes the presentation, diagnosis, and subsequent manage-
⁎ Corresponding author. Tel.: +90 412 248 8001, +90 507 607 4662 (GSM);
fax: +90 412 248 8523.
E-mail address: m.hanifi-okur@hotmail.com (M.H. Okur).
ment of pediatric TDR in children admitted during a 12-year period to
a single center.
1. Patients and methods
Data from 22 patients presenting with TDR were collected in a
retrospective analysis of admissions between January 2000 and
December 2011. Relevant information obtained included patient age
at diagnosis, sex, mechanism of injury, side of injury, organs herniated
into the thorax, ISS values, type of surgical procedures, length of
hospital stay, morbidity and mortality. Patients were divided into
subgroups based on injury type (firearm and other injuries) and ISS
values (below or above the cutoff value of 16). In our department, a
chest radiograph (CXR) was the first diagnostic study for patients with
suspected diaphragmatic rupture. Cases with suspicious CXR were
evaluated with MDCT, including multiplanar reconstruction or
volume rendering, if hemodynamically stable. MDCT was used not
only to confirm the diagnosis of suspected traumatic diaphragmatic
rupture but also to diagnose other associated injuries and help plan
management accordingly. Statistical analyses were performed using
the Statistical Package for the Social Sciences (SPSS) version 13.0

0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.11.056
 M.H. Okur et al. / Journal of Pediatric Surgery 49 (2014) 420–423 421

(SPSS, Inc., Chicago, IL, USA). Data are presented as mean ± standard computed tomography indicated that the chest tube had penetrated
deviation or n (%). The differences between the subgroups were the herniated stomach in the thorax. The patient underwent a
analyzed using the chi-square test or the Fisher’s exact test. A p-value laparotomy, and after irrigating the thorax, the stomach and the
less than 0.05 was considered significant. diaphragm were repaired primarily.
While 19 patients underwent laparotomy alone, three patients
required both thoracic and abdominal interventions. One of these
2. Results
patients underwent a laparotomy through a median incision and a
right thoracotomy owing to multiple injuries caused by gunshots. A
Between 2000 and 2011, approximately 15,000 pediatric trauma
grade III liver injury, vena cava injury, and small intestinal injury
patients were admitted to the emergency clinic at Dicle University;
observed during the laparotomy were repaired primarily. In addition,
twenty-two were diagnosed with TDR. The mean patient age was
a lung injury was repaired through the right thoracotomy, and a
9 years (range 2–15 years). Ten patients (45%) presented with blunt
bleeding intercostal artery was ligated. The patient, who could not be
trauma. The remaining twelve (55%) had penetrating traumas: seven
stabilized despite blood and fluid resuscitation, succumbed during the
firearm injuries and five stab wounds. Diaphragmatic rupture was
surgery. This patient was one of the seven patients who had sustained
left-sided in 20 (91%) patients and right-sided in two (9%) patients.
firearm injuries. The patient’s ISS was greater than 16 (ISS = 29). In
Twenty patients presented with herniation (displacement of an organ
another patient who underwent both thoracic and abdominal
into the thorax), primarily of the stomach and the transverse colon.
interventions, a left thoracotomy was performed after more than
Other clinical features are presented in Table 1. Among these patients,
1400 cc of blood had been drained via chest tube. Following the
seventeen were diagnosed preoperatively. Diagnoses were based on
ligation of a bleeding intercostal artery, a diaphragm injury was
CXR for fourteen patients. MDCT was performed on twelve patients,
detected and repaired. Subsequently, an exploratory laparotomy was
nine of whom were diagnosed via CXR, while the remaining three had
performed through a median incision, and no additional pathologies
suspicious CXRs and required MDCT for definitive diagnosis. The other
were observed. In the third patient who underwent both thoracic and
five patients were diagnosed intraoperatively as they were hemody-
abdominal interventions, a liver laceration was observed during the
namically unstable and required immediate surgical intervention. All
repair of the diaphragmatic hernia through a right thoracotomy. A
five patients had ISS values greater than 16; four of the five cases were
laparotomy was additionally performed to repair the liver laceration.
firearm injuries.
Four patients had postoperative complications. Empyema devel-
All patients underwent primary diaphragmatic repair and tube
oped in the patient with the iatrogenic stomach injury; and
thoracostomy. The seven patients with isolated injuries needed no
decortication was performed on the 10th day, and he was discharged
further procedures. Among the remaining patients, fourteen were
on the 20th day. The remaining three patients presented to our clinic
treated for additional injuries and one patient was treated for an
owing to ileus and two of them were conservatively treated. The third
iatrogenic organ injury. The additional injuries and the performed
patient did not respond to conservative treatment, and an intussus-
procedures are presented in Table 1. In the single patient with an
ception 20 cm distal to the ligament of Treitz was observed on
iatrogenic injury, the stomach was injured after having herniated into
abdominal ultrasonography. The patient underwent a relaparotomy,
the thorax. The patient’s history revealed that a chest tube had been
and the intussusception was manually reduced.
inserted at an outside hospital owing to suspected pneumothorax
Complications were observed in two of seven patients with
which was then observed to drain gastric contents. The CXR and
firearm injury. Complications were also observed in two out of the
other 15 patients, but no significant difference between the
Table 1
complication rates was determined (p = 0.565). The two firearm
Clinical profile. injury patients had ISS values below 16, and the two non-firearm
injury patients had ISS values above 16; no significant difference
n (%)
between ISS values above and below 16 was determined (p = 0.565).
No. of patients 22
Male 18 (82)
Female 4 (18)
Mean age, years (range) 9 (2–15) 3. Discussion
Mechanism of injury
Blunt 10 (45) TDR may originate from blunt or penetrating thoracoabdominal
Traffic accident 7 (32) trauma. The main causes of blunt trauma observed in our study were
Falls 3 (13)
Penetrating 12 (55)
falls from heights and motor vehicle accidents, while penetrating
Firearms 7 (32) trauma resulted from gunshot and stab wounds. One collective review
Knives or skewers 5 (23) previously suggested that 75% of observed TDR were owing to blunt
Location of rupture trauma, and 25% owing to penetrating trauma [8]. The incidence of
Left diaphragm 20 (91)
penetrating injuries of 55% (12/22) in the pediatric age group in this
Right diaphragm 2(9)
The mean ISS (range) report is much different from what is reported in most of the
Blunt 16 (11–22) literature, whether coming from developed or developing countries.
Penetrating 20 (11–29) This high percentage of violence among children may reflect a form of
Mean diaphragmatic defect diameter, cm (range) child battering. In a large series of 20,500 trauma patients seen over a
Blunt 5 (4–7)
Penetran 2 (2–3)
21-year period, Ramos et al. reported only 15 children (0.07%) with
Associated injuries (Additional procedures) TDR [1]. Brandt et al. reported 13 children with TDR seen over a period
Stomach 7 (PR, 7) of 18 years [2], and Shehata et al. reported 10 children with TDR over a
Spleen 6 (PR, 2; CM, 4) period of six years [9]. Our study included 15,000 trauma patients over
Small intestine 2 (PR, 1; RA, 1)
a period of 11 years, 22 of whom were children presenting with TDR.
Liver 2 PR
Pancreas 1 CM The male incidence rate (81%) in our study was similar to that of other
Kidney 1 CM studies [9,10]. TDR commonly affects the left side [1]. Left diaphrag-
Gastroesophageal junction 1 PR matic rupture is more frequent following trauma owing to the weaker
ISS; Injury Severity Score, PR; Primary Repair, CM; Conservative Management, RA; structure of that side. The right hemidiaphragm is congenitally
Resection Anastomosis. stronger than the left side, and the liver serves as extra protection
422 M.H. Okur et al. / Journal of Pediatric Surgery 49 (2014) 420–423

and support [1]. A higher rate of left-sided (91%) diaphragmatic injury

was encountered in our series.
The diagnosis of a ruptured diaphragm is frequently missed in the
first post-traumatic assessment owing to the presence of associated
injuries. CXR is the most important diagnostic study; however, a high
index of suspicion is required [10,11]. In various studies, CXR has been
reported to provide a diagnosis of TDR in 46–87% of cases [9,12]. In our
study, 64% of patients were diagnosed by primary CXR alone (Fig. 1).
For patients for whom a definitive diagnosis cannot be established by
CXR, or who have suspicious findings (including indistinct or elevated
hemidiaphragm, rib fractures, pneumothoraces, hemothoraces, and
pleural effusions), MDCT is recommended [13,14]. In our study, in
three patients TDR was diagnosed using MDCT (Fig. 2). MDCT clearly
depicts the anatomy via three-dimensional reconstructions, and it
highlights other associated organ injuries. In scientific visualization
and computer graphics, volume rendering (VR) is a set of techniques
used to display a two-dimensional (2D) projection of a three-
dimensional (3D), discretely-sampled dataset. Multiplanar recon-
struction (MPR) is a term used in medical imaging that refers to the
reconstruction of images in the coronal and sagittal planes in
conjunction with the original axial dataset (Fig. 3A and B). Patients
should be hemodynamically stable for MDCT examinations [15,16]. In
our study, accurate and detailed visualization of the size, location, and
extension of diaphragmatic rupture and associated organ injury was
revealed using 3D VR images generated from a 64-slice MDCT in
twelve (55%) patients. In a study by Karnak et al., a diagnosis of

Fig. 2. Right-sided diaphragmatic rupture (blunt trauma). 2A) Suspicious chest

radiograph showing elevated right hemi-diaphragm. 2B) Sagittal multiplanar recon-
struction image showing the dome of the herniated liver, diaphragm and herniated
liver limit.

diaphragmatic rupture was determined preoperatively in 87% of 15

Fig. 1. Left-sided diaphragmatic rupture after blunt trauma. 1A) Axial CT image:
intrathoracic bowel loops (arrows). 1B) Chest radiograph showing bowel loops filled
with gas in the left hemithorax.
patients [12]. Our preoperative diagnosis rate was quite similar (82%).
Laparotomy alone was performed on 19 patients, while thoracot-
omy plus laparotomy were performed on the remaining three cases.
Recently, laparoscopy and thoracoscopy were reported to be helpful
in both the diagnosis and treatment of TDR [17,18]. In our opinion,
although the surgical approach depends on the localization, size, and
stability of the trauma, as well as associated injuries, the abdominal
approach should be the procedure of choice for patients with severe
trauma, as it provides better exposure. In this study, thoracotomy and
laparotomy were applied together in three patients. One of these
patients was exposed to multiple traumas. The other two patients
were not preoperatively evaluated in detail because they were in
shock when taken to the operating room. Therefore, we performed
thoracotomy and laparotomy. However it would also have been
possible to begin with a thoracoabdominal incision.
Associated abdominal injuries are common. The liver (38%) and
spleen (34%) are the most often reported associated injuries in the
literature [8]. In our study, gastric (40%), splenic (26%), and hepatic
(13%) injuries were most common. Renal, pancreatic and esophageal
injuries were also noted, but less commonly, encountered. While
Ramos et al. reported a gastrointestinal perforation rate of 33% in their
series comprising 15 patients with two penetrating and 13 blunt
traumas, we observed a rate of 45% (10 cases) in our study consisting
of 22 patients with 12 penetrating and 10 blunt traumas [1]. In our
study, eight perforations (36%) were caused by penetrating trauma,
while two (9%) were owing to blunt trauma. Stomach perforations,
which are the most commonly reported type of rarely-occurring
iatrogenic complications in the literature [11,19], were observed in
two patients. The diameter of the diaphragmatic defect was 5 cm
 M.H. Okur et al. / Journal of Pediatric Surgery 49 (2014) 420–423
Fig. 3. Left-sided penetrating diaphragmatic rupture. 3A) Sagittal multiplanar
reconstruction images: posterior hemi-diaphragmatic rupture (arrow). 3B) Volume
rendering CT image: posterolateral diaphragmatic defect (arrow).
(range 4–7 cm) on average in blunt trauma cases, and 2 cm (range 2–
3 cm) in penetrating trauma cases. In our study, the diaphragmatic
defect size did not affect mortality.
Special care should be taken in patients with penetrating trauma,
as their defects may be smaller and less noticeable than in patients
with blunt trauma. In the present series, we encountered one instance
of postoperative intussusception, which frequently follows intra-
abdominal procedures. Karnak et al. also reported a case of
intussusception which developed after TDR repair [12]. In children
who have undergone intra-abdominal surgery and who show
423
evidence of early intestinal obstruction or ileus, postoperative
intussusception should be considered.
The mean ISS for our patients was 19 (range 11–29). Children with
TDR have lower ISS values compared to adults whose scores average
21 (range 9–50) in the literature [20]. In our study, the patient who
died had an ISS value of 29; however, high ISS values do not always
correspond to high mortality. The patient had a major firearm-related
vascular injury, and the presence of major vascular and/or head
injuries has a direct impact on mortality. None of the 15 patients with
nonfirearm injuries died. In our study, the diaphragmatic defect size
did not affect mortality. We reported one fatality (4.5%), a mortality
rate lower than in most of the pediatric series in the literature [1,19].
TDR, while uncommon, should be considered in cases of
thoracoabdominal injuries. In the majority of these patients, this is
the result of severe trauma and so patients may have other associated
injuries. Although the chest radiograph may be diagnostic, multi-
detector computed tomography, including multiplanar reconstruction
or volume rendering, can be helpful to verify the diagnosis and detect
associated injuries. Operative strategies should be planned based on
the localization, size of the defect, associated injuries and stability of
the patient.
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