FIGURE 115.11 This 5-year-old boy was on a snowmobile when it crashed into a tree Initially there was no respiratory distress, but upon arrival at the emergency department, the patient became tachypneic and required oxygen Breath sounds were reportedly normal Chest radiograph showed a left-sided diaphragmatic hernia This injury was surgically repaired in the operating room, and the patient did well postoperatively Motor vehicle collisions are the most common mechanism of injury The direction of impact may play a role in the side and type of diaphragmatic rupture A lateral torso impact has been shown to be three times more likely to result in a ruptured diaphragm than a frontal impact and the rupture tends to be on the same side as the impact Associated injuries such as pulmonary contusions, hepatic or splenic lacerations, and fractures of the extremities are present in more than 75% of patients Thoracic aortic injuries have been reported in up to 10% of adults with diaphragmatic injury and should be considered in children with diaphragmatic trauma Patients may present with respiratory distress and have a scaphoid abdomen, although they are more likely to be symptomatic from associated injuries than from the diaphragmatic rupture itself The verbal child may complain of chest