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Case Reports
. 2024 Jul 17:11:1369255.
doi: 10.3389/fsurg.2024.1369255. eCollection 2024.

Case Report: Surgical challenges and insights in a child with a blunt left diaphragmatic and pericardial rupture and heart subluxation

Melaku Tessema Kassie  1 , Motuma Gonfa Ayana  2 , Ruth Betremariam Abebe  2 , Befikadu Molalign Abebe  2
Affiliations
Case Reports

Case Report: Surgical challenges and insights in a child with a blunt left diaphragmatic and pericardial rupture and heart subluxation

Melaku Tessema Kassie et al. Front Surg. .

Abstract

Introduction: Blunt diaphragmatic rupture (BTDR) is a rare condition that can occur in children following high-energy blunt thoracoabdominal trauma. In less than 1% of the cases, pericardial rupture can coexist with a BTDR. A coexistence of BTDR and pericardial rupture can result in displacement of the heart and is associated with high mortality. Clinical presentation is non-specific and requires a high index of suspicion for early management.

Case presentation: A 4-year-old child presented to the emergency unit of our hospital following high-energy trauma with severe respiratory distress. Initially, a left-side chest tube was inserted, but it resulted in no clinical improvement. A chest x-ray showed a collapse of the left lung with a herniation of bowel loops into the left hemithorax. An exploratory laparotomy was done, which revealed a 10 cm × 4 cm defect in the left hemidiaphragm with a medial extension involving the pericardium. The fundus of the stomach and left lobe of the liver were displaced into the pericardial space, pushing the cardiac apex posteriorly to the right side. Concomitantly, the transverse colon and small bowel were displaced into the left pleural space. After the reduction of the herniated abdominal viscera back into the peritoneal cavity, the pericardial sac was repaired by employing an interrupted resorbable suture, while the diaphragmatic defect was repaired by using a horizontal mattress. No other injuries were identified and the abdomen was closed in layers.

Conclusion: BTDR with pericardial rupture is an elusive condition with a high mortality rate that necessitates a high index of clinical suspicion. Early surgical repair of the defect with a reduction of herniated organs can reduce morbidity and mortality.

Keywords: blunt trauma; diaphragmatic rupture; heart subluxation; pediatric trauma; pericardial tear.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
The yellow arrow indicates bowel loops with haustral markings and gas in the left hemithorax. The red arrow indicates a significant shift of the mediastinum to the right side. The image also shows significant tracheal deviation outlined by the yellow dashed line.
Figure 2
Figure 2
The white arrow indicates the pericardial sac tear. The white dashed line outlines the diaphragmatic defect. “Dphr” labels the left hemidiaphragm.
Figure 3
Figure 3
The yellow arrow indicates the transverse colon, and DPHR indicates the diaphragm.
Figure 4
Figure 4
An AP chest x-ray taken 48 h postoperation prior to the removal of the chest tube.
See this image and copyright information in PMC

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