diaphragmatic rupture is a very rare injury , which occurs in less than 2% of all blunt injuries to the abdominal area .
injury to the diaphragm is most commonly caused by a sudden change in intra - abdominal pressure , most commonly by a blunt blow to the abdominal area .
another cause of diaphragmatic rupture is sudden decelaration , when abdominal organs continue movement due to inertia , and tear through the diaphragm .
diaphragmatic rupture often manifests itself later than other injuries , after an organ progressively herniates into the pleural cavity .
we present a patient with a delayed diagnose of right sided diaphragmatic rupture with a complicated post - operation state .
a 11-year - old boy , 35 kg , was involved in a car crash , as the nearside passanger .
he was admitted to the intensive care unit , where he was intubated and ventilated .
computed tompgraphy ( ct ) of the chest and abdomen showed a subcapsular liver hematom , right lung contusion and a minor hemothorax .
the patient also had a right femur diaphysis fracture , which was resolved by external fixation , and a right acetabulum fracture without dislocation .
on the second post - traumatic day , 1 hour after transfering to spontaneous ventilation , the patient underwent a breathing distress . a x - ray and ct of the chest
was carried out ( figure 1 ) , with the find of thoracicaly herniated liver .
a right sided , subcostal laparotomy was carried out , where the liver was found to be completely herniated intrathoracicaly .
the liver was herniated into the chest through a 15 cm diaphragm rupture , like a button through a buttonhole ( figure 2 ) .
a suture of the defect was carried out by seperate matress sutures ( 30 ethibond ) .
due to dyspnoea , and a fluidothorax in the right pleuric cavity , the patient was tubed again , a pleuric drain was also applied . at the 7 post - traumatic day , the drain was removed .
9 post - traumatic day , a ct was carried out and a thoracoscopic surgery , with the goal of aspirating the fluidothorax and placement of a right side thoracic drain , indicated .
after this , the ventilation improved and the patient was extubated on the 14 post - traumatic day .
figure 1liver herniation intrathoracicaly ( contrast enhanced computed tomography , coronal multi - planar reformatting ) . 
 
( contrast enhanced computed tomography , coronal multi - planar reformatting ) . 
 figure 2defect in the diaphragma and herniated liver into the thoracic cavity . 
 
the edges of the muscle are fuller than the middle area , which is made up from a thin aponeurosis called centrum tendineum .
left - sided ruptures of the diaphragm are described in up to 70% of all cases .
left - sided ruptures can result in a herniated stomach , small intestine , colon , spleen and omentum .
right - sided diaphragm ruptures , occuring in 30% of all cases , result in the herniation of the liver . the reason for this in - equality is that the right side of the diaphragm is , in a way , protected by the liver .
however , if a rupture to the right side does occur , it often results in serious or even fatal injury .
a right sided diaphragm rupture is often complicated by damage to blood vessels , most commonly vena cava inferion , the hepatic veins can also be damaged . both - sided injury to diaphragm occurs in only 2% of all diaphragm injuries .
diaphragm injuries are most commonly accompanied by fractures of the pelvis , damage to the spleen , rib fracture , damage of the liver , contusion or rippage of a lung .
our patient , in adition to a ruptured diaphragm , had a brain comotion , right lung contusion , subcapsular liver hematom , dislocated right femur fracture and a right acetabulum fracture , without dislocation .
with comparison to adult patients , we find a larger number of isolated diaphragm ruptures amongst children . in larger scales of patients
, isolated injury occurs in roughly 50% of all cases of injured children , and in 20% off all cases of injured adults .
the injury is diagnosed more in boys than girls , largely due to the fact , that boys have a higher incident rate than girls .
most common cause of diaphragm injury is a blunt injury in the abdominal area , often caused by traffic accidents , or falls from heights . in our country
, we do not encounter penetrating wounds to the abdomen or chest in children . in north america ,
the number of stab and shot wounds is larger . at the johns hopkins hospital in baltimore ,
the number of patients with diaphragm injury was 14 over the span of 15 years , with 11 of these being a penetrating wound . in europe ,
the rate of diaphragm injury caused by a blunt blow is 80100% . in blunt injuries to the diaphragm ,
the laceration is of larger scale , in our case , the laceration was 15 cm long .
this makes herniation of internal organs easier . in injuries caused by stabbing , the defect in the diaphragm ranges up to 2 cm , in this case , the most common herniation is that of the omentum , not of an internal organ .
the danger of herniation into smaller defects in the diaphragm is that of strangulation followed by the perforation of an organ .
this danger , which occurs during herniation through smaller defects , is caused by pressure differences between thoracic and abdominal cavities , which is normally 210 mm hg and during the valsalvov manouver increases up to 100 mm hg .
a diaphragmatic rupture can present itself immediately after injury , but more commonly , complications occur proggressively .
when the patient is tubed , the ventilation pressure does not allow herniation of an organ , which occurs when the patient is extubated .
the rupture of the diaphragma was right sided , and the liver herniation occured after extubation of the patient .
symptoms , found in patients with diaphragma injury are pain in the epigastrium , shoulder pain , respiratory problems , intestinal obstructions . during an examination of a patient with a small intestine herniation
only a very small number of patients manifest symptoms of a ruptured diaphragm relatively longer after the primary injury .
these patients have only minor symptoms , which can , nevertheless , result in a herniation of an organ . in the case of chronic herniation with a late diagnose ,
diagnostical methods , used to diagnose diaphragm ruptures are x - ray , ultrasound and ct .
the basic method is x - ray , which shows elevation or decrease in sharpness of the diapghragm conture , occluded hemithorax caused by abdominal organs in the thoracic cavity , hemopneumothorax .
sometimes a x - ray of a stomach or colon herniation can be confused with a pneumothorax .
another used examination method is ultrasound , the advantages being non - invasivity and easy accesability .
hard to diagnose is a diaphragm rupture , that is not accompanied by herniated organs . in this case ,
the most common access is through laparotomy ( in 74% ) , thoracotomy ( 18% ) and from thoracoabdominal access ( 8% ) .
the abdominal access is encouraged , because other organs in the abdominal cavity are often damaged too . in our case , we opted for the abdominal access .
the liver was herniated into the thoracical cavity through the diaphragma like a button through a buttonhole .
post - operational progress was complicated by atelectasis of the bottom right lobe and a fluidothorax , thoracoscopic revision was needed on the 9 post - operational day . in the university department in mansoura , egypt , where 44 patients with diaphragma rupture are placed , the thoracotomy access is prefered in 84% .
thoracotomy acces is also encouraged at most departments in cases of older date , due to the possibility of adhesion in the thorax area .
now , laparoscopic or thoracoscopic access is gaining popularity and is being encouraged . in our case , during laparoscopic revision , where the access was wide and the defect in the diaphragma well accessible , the reponation was difficult , because of the large difference between the size of the diaphragmatic defect and herniated liver . in this case , laparoscopic treatment would have been very difficult .
other complications that can occur during diaphragmatic injury are pneumonia , empyem , subphrenical or intraabdominal absces , especially if a herniated organ is damaged .
after injury to the diaphragm , good drainage of the thoracic and abdominal cavity is recommended . during the injury ,
branches of the phrenical nerv can be damaged , causing partial den - ervation of the diaphragm , and lung complications .
therefore , after diaphragmatic injury , it is recommended that long - term follow up is established .
traumatic rupture of the diaphragm is rare and diagnosis can be late in some cases .
it is important to remember the possibility of this injury and always check the diaphragm for any signs of damage , when dealing with abdomenal injuries .
 right - sided traumatic diaphragmatic rupture in childhood is a very rare injury . 
 diaphragmatic rupture often manifests itself later , after an organ progressively herniates into the pleural cavity . 
 when the patient is tubed , the ventilation pressure does not allow herniation of an organ , which occurs when the patient is ex - tubed . 
 we present a patient with a delayed diagnose of right sided diaphragmatic rupture with a complicated post - operation state . 
Introduction
Case Report
Discussion
Conclusions