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Paediatric Traumatic Diaphragmatic Rupture

Augustine Olugbemi1,EzekielOgunleye1, Olowoyeye Omodele1,Joel Eyekpegha2, Akerele Oluwaseye1, Daniel Kehinde1, OyebolaAdekola1

1.Lagos University Teaching Hospital, Lagos, Nigeria

2.Obafemi Awolowo University Teaching Hospital, Nigeria

Correspondence to: Dr.Adekola Oyebola, CMUL/LUTH PMB 12003, Surulere, Lagos, Nigeria; email: oyebolaadekola@yahoo.com

Summary

Traumatic diaphragmatic rupture is not a common injury in children. It is an important cause of morbidity and mortality, though diagnosis may be missed or delayed with atypical clinical presentation and confounding radiological features. A 4-year-old male presented with periumbilical abdominal pain, bilious vomiting, fever and progressive difficulty in breathing for two days. He had complained of vague left-side chest pain on return from the swimming pool about 6 weeks earlier. An initial chest radiograph showed a non-outlined left hemidiaphragm, a left pneumothorax, rightward mediastinal shift and suspected bowel in the chest. He could not afford a CT scan, hence a repeat chest radiograph was performed, which outlined the stomach with an air-fluid level in the left hemithorax.

Keywords: Traumatic Diaphragmatic Rupture, Child, Atypical Chest pain, Blunt injury

Ann Afr Surg. 2020; 17(1):35–38.

DOI: http://dx.doi.org/10.4314/aas.v17i1.9

Conflicts of Interest: None

Funding: None

© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Traumatic diaphragmatic rupture (TDR) in the presence of other injuries and owing to its rarity may be easily missed in children (1,2). When presentation is delayed, morbidity and mortality rates increase proportionately (1,2). TDR may mimic conditions such as pneumothorax and bowel obstruction. It is important to make the correct diagnosis as management for these entities is different, and the wrong treatment may be catastrophic. A 4-year-old boy was referred to us following a 2-day history of periumbilical abdominal pain and bilious vomiting. There was no abdominal distension or constipation. He had developed a fever and progressive difficulty with breathing at presentation. Further history obtained from the parents revealed that he had complained of vague left side chest pain on return from the swimming pool about 6 weeks earlier. The pool attendant did not report witnessing any trauma. The househelp was said to have used hot compress on the chest for several days without the knowledge of the parents. Findings at presentation revealed a conscious child, well oriented in time, place and person and febrile (37.8º C). No physical evidence of trauma was seen. Child was in severe respiratory distress (RR, 46 breaths per minute). The trachea was deviated to the right. There was increased percussion notes and reduced air entry on the left hemithorax. Chest auscultation produced no bowel sounds. The abdomen was flat and moved with respiration. No abdominal wall tenderness or palpably enlarged organs were seen, and bowel sounds were normal. He had emergency exploratory thoracotomy; operative findings revealed a 4-cm tear through the tendinous part of the left hemidiaphragm through which the stomach and omentum had herniated. The initial assessment was small bowel obstruction to R/O left pneumothorax. A nasogastric tube was passed, which drained bilious fluid. Full blood count, electrolytes, urea and creatinine were within normal range. The chest radiograph revealed a non-outlined left hemidiaphragm, a left pneumothorax, rightward mediastinal shift and suspected bowel in the chest (Fig. 1). An emergency left posterolateral exploratory thoracotomy was performed under general anaesthesia relaxant technique.