The Hidden Injury: Delayed Discovery of Traumatic Diaphragmatic Hernia in a Child

Abstract

Introduction Traumatic diaphragmatic hernia (TDH) is a rare pediatric injury (<1% of trauma cases). Leftsided defects are more common but may be overlooked, particularly when initial imaging is negative. Delayed diagnosis increases the risk of visceral herniation, respiratory compromise, and life-threatening complications [1]. Case Presentation An 11-year-old girl presented with severe respiratory distress, abdominal pain, and persistent vomiting. She was initially treated for suspected pneumonia; however, chest X-ray revealed herniation of the stomach into the right thoracic cavity. Medical history revealed severe polytrauma with predominant head injury following a motor vehicle accident two years earlier, with an initially unremarkable thoracic CT scan. In the preceding months, the patient experienced recurrent self-limiting episodes of vomiting and abdominal pain. The patient was transferred to a tertiary center where emergency laparotomy revealed herniation of a markedly distended stomach containing approximately 4 liters of gastric contents, along with the left hepatic lobe, through a 5-cm diaphragmatic defect. Primary diaphragmatic repair was performed. Postoperatively, the patient developed right lung consolidation, suspected to be aspiration pneumonia, requiring high-flow oxygen therapy. Broad-spectrum antibiotics were initiated. The patient was discharged in good condition 9 days postoperatively and remained asymptomatic at follow-up. Discussion Traumatic diaphragmatic rupture in children is uncommon and often clinically occult, particularly in polytrauma patients where associated injuries dominate initial management. Respiratory symptoms are frequently nonspecific, and normal breath sounds or oxygen saturation do not exclude diaphragmatic injury [2]. Small tears may remain undetected on initial imaging and enlarge over time, allowing delayed herniation of abdominal viscera months or years after trauma. From a pediatric surgical standpoint, timely recognition is critical, as leftsided defects carry a high risk of gastric or intestinal incarceration, necrosis, and perforation [2,3]. Once diagnosed, surgical repair should not be delayed to prevent life-threatening complications [4]. Conclusions In pediatric patients with respiratory symptoms and a history of high-energy blunt trauma, TDH should be considered to avoid delayed diagnosis and prevent life-threatening complications.