Traumatic diaphragmatic rupture in a pediatric patient: a case report

Diaphragmatic rupture following blunt abdominal trauma is an uncommon life-threatening injury in children. In addition to its high mortality rate, there is a significant amount of morbidity associated with this injury. Emergency medicine physicians must maintain a high index of suspicion for diaphragmatic rupture and its associated complications when evaluating victims of blunt abdominal trauma.     

Stricture of the common bile duct secondary to blunt abdominal trauma

A 3-year- 8-month-old girl developed obstructive jaundice associated with stricture of the distal end of the common bile duct 7 months after blunt abdominal trauma. Ultrasonography, computerised tomography, and percutaneous trans-hepatic cholangiography made the anatomical diagnosis before surgical reconstruction. Histological examination of the retroperitoneal tissue near the site of the stricture showed evidence of previous bile leakage due to rupture of the duct. Relief of obstruction was achieved by a Roux-en-Y choledochojejunostomy with complete resolution of symptoms and restoration of normal liver function. Offprint requests to: H. C. O Martin     

Traumatic aortic rupture in the pediatric population

A retrospective review was undertaken to determine the incidence of, and radiologic findings associated with aortic rupture resulting from blunt chest trauma in children. Records and imaging data of 54 consecutive pediatric patients admitted over a 2 year period to a pediatric trauma center after sustaining blunt chest trauma were reviewed. Four of 54 (7.4%) had a documented aortic tear. Plain films were evaluated for 7 radiographic signs described in the adult literature as sensitive indicators of aortic rupture, including abnormal aortic contour and mediastinal widening. Two groups of patients were defined: Group 1 (n=4) had aortic rupture confirmed by angiography or operation and Group 2 (n=50) with no angiographic investigation. All patients in Group 1 demonstrated mediastinal widening and abnormal aortic contour; however, 50 percent of patients in Group 2 had similar findings. Computed tomograms of the thorax where obtained were reviewed, including 1 patient from Group 1 and 6 patients from Group 2. The aortic tear was well demonstrated in the one patient from Group 1; however, the remaining computed tomograms were deemed inadequate for reliable exclusion of significant aortic injury. Plain chest radiographic findings in 5 consecutive children who underwent aortography in the two years subsequent to this series, including 2 additional patients with aortic rupture, were also reviewed, with similar results. In conclusion, traumatic aortic rupture in the pediatric population may be more common than previously reported. Plain film findings of aortic rupture in children are similar to those in adults, and are sensitive but non-specific. Currently, at least in our institution, this injury may be underinvestigated. Angiography remains the modality of choice in the diagnosis of aortic tears in children.     

Splenic salvage in children with blunt pancreatic transection

Delayed recognition of pancreatic transection after blunt abdominal trauma contributes significantly to the high morbidity and mortality of this lesion. The classical treatment of this injury has been distal pancreatectomy and splenectomy. Over the past 5 years, we have treated six children with complete transection of the pancreas due to blunt trauma to the abdomen. Computed tomography (CT) was useful in defining the site of transection in two of three patients. Three children had a delay in diagnosis of 3–49 days; they all developed complications (e. g. pseudocyst, abscess, fistula) prior to definitive surgery. The spleen was salvaged in all sic patients: five had partial pancreatectomy and one had cystogastrostomy. Following pancreatic resection, there was no morbidity or pancreatic insufficiency over an average follow-up period of 40 months. The mortality in this series was 0%. When pancreatic injury is suspected in blunt abdominal trauma, CT is recommended for early diagnosis of pancreatic transection. In stable patients with this injury, distal pancreatectomy with splenic salvage is a feasible and effective treatment that preserves adequate pancreatic function and lowers the incidence of complications. Offprint requests to: A. J. Razzouk     

Appendicitis after blunt abdominal trauma in the pediatric patient — fact or fancy?

At the Hospital for Sick Children, Toronto, about 300 children a year are operated on with the diagnosis of acute appendicitis. In four such cases in the last 15 years blunt abdominal trauma preceded the acute appendicitis. The four children (three boys and one girl) ranged from 6 to 15 years. Within 7 days of the blunt abdominal trauma the patients developed signs and symptoms of peritonitis requiring laparotomy. They all had an appendectomy for acute appendicitis; one boy also had 150 ml of old blood from a splenic hematoma. Although any child who has suffered blunt abdominal trauma and then slowly develops peritoneal signs in the lower abdomen may be suspected of having acute appendicitis, it seems reasonable to assume that this sequence of events is more coincidence than real.     

Analysis of the value of imaging as part of the follow-up of splenic injury in children

Objective: A recent article suggested that routine follow-up imaging is still frequently used in the conservative management of splenic trauma in children. The purpose of this study was to use decision analysis to assess the value of routine imaging as part of the long-term follow-up of splenic injury in children managed nonoperatively. Methods: A literature review (1970–1999) on the management of blunt splenic trauma in children was performed. Data, including the use of follow-up imaging and the occurrence of delayed splenic rupture and death, on those patients managed nonoperatively were collected. The data were used to construct a decision tree. A Poisson distribution was used to determine the risk of delayed splenic rupture. Results: Information was extracted from 26 cohort studies. Nineteen of these studies were retrospective and six were prospective. One study had both retrospective and prospective arms. The study population consisted of 1,083 children. Of these patients, 920 (85 %) underwent routine follow-up imaging (US, CT, or scintigraphy). Follow-up imaging was either not performed or selectively performed in 163 patients (15 %). No cases of post-discharge splenic rupture or death were encountered in any of these groups. The maximum risk of delayed splenic rupture in the entire group was 0.3 % (0–3.7 cases). Conclusion: . The risk of delayed splenic rupture following blunt injury in children is very low, and is apparently unaffected by imaging protocols. No deaths, even in cases of delayed presentation, were identified in our study. These findings do not support the use of routine follow-up imaging of children with blunt splenic trauma. Received: 17 November 2000/Accepted: 25 July 2001     

Blunt liver trauma in children

Diagnostic evaluation and treatment of blunt liver trauma in children have changed essentially over the last decades. In the period between January 1975 and December 2002, a total of 45 children, 18 girls and 27 boys, between the ages of 1 and 16 years (mean 8.19) were treated for liver rupture following blunt abdominal trauma. The most common causes of injury were traffic accidents (49%), followed by falls (22%), direct trauma due to impact (20%) and being run over by a vehicle (9%). A total of 26 patients had one or more concomitant injuries; the injury severity score was between 16 and 57 (mean 22.9), and 16 patients had additional injuries to other solid abdominal organs. Since we last used laparotomies to explore the abdomen and manage liver ruptures in 1984, we divided our patients into two groups with respect to the choice of diagnostic and treatment modalities: group I, consisting of children treated before 1984, and group II, consisting of children treated after 1985. In group I (n=12), a diagnosis was made in eight cases based on exploratory laparotomy, in two cases based on sonography and laparoscopy, in one case based on laparoscopy only, and in another case based on sonography only. In eight cases the rupture was treated operatively; there was one postsurgical sepsis and one ileus due to adhesions. One child hemorrhaged to death when the vena cava ruptured during surgery. In group II (n=33), sonography was sufficient for a diagnosis in 18 cases. In 12 cases an additional computed tomographic scan was performed following initial sonography, and in three cases a diagnostic laparotomy was done elsewhere. In five cases the rupture was treated operatively in other hospitals. Twenty-eight patients could be treated conservatively and without any complications. One child died 3 days after the accident as a result of a severe brain injury. Over the past 15 years we have seen a clear tendency toward conservative treatment of our patients, which is also in agreement with current literature. Initial sonography, supplemented by computed tomography when necessary, allows not only noninvasive initial diagnostic evaluation but is also helpful in the further course in hemodynamic stable patients. All patients who had been treated conservatively (n=30) had no complications related to the liver rupture.     

The value of routine follow-up imaging in pediatric blunt liver trauma

Purpose. To evaluate the utility of routine follow-up computed tomography (CT) and/or ultrasound (US) scans in children with blunt hepatic trauma initially managed non-operatively. Materials and methods. Review of the records of 66 children with proven blunt liver injury on initial CT scan, who were initially managed non-operatively during the period January 1991 to December 1996. Follow-up CT and US studies were analyzed and correlated with clinical outcome. Results. Of the 66 children, 30 were not followed with any imaging study, 26 were followed with US only, 7 with CT only and 3 with US and CT. Disappearance of the liver lesion(s) was seen in 25 patients (range: 6 days – 14 months) and decrease in size was noted in 10. In one patient, who developed abdominal and right shoulder pain 10 days after presentation with subsequent hemoglobin drop, CT showed contrast medium extravasation into a hepatic hematoma from portal vein injury that required surgery. Conclusion. Our series suggests that in asymptomatic patients, US and CT follow-up studies do not provide the additional information needed for patient management. Therefore, we believe that in asymptomatic children with blunt hepatic trauma who are clinically stable, routine follow-up imaging studies are of very limited value. Received: 13 September 1999 Accepted: 6 March 2000     

Rupture of the right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma

 The diagnosis of right-sided diaphragmatic rupture (RDR) due to blunt abdominal trauma is often missed in the acute setting, especially in the absence of other thoracoabdominal injuries. We describe two such children. The problems associated with the diagnosis and management of RDR are discussed to emphasize the need to have a high index of suspicion for this entity.     

Paediatric blunt abdominal trauma: challenges of management in a developing country.

BACKGROUND: In developed countries, the availability of advanced imaging techniques has reduced the necessity for laparotomy following blunt abdominal trauma in children. Laparotomy rates still remain high in developing countries where these advanced imaging techniques are lacking. A simple management protocol to identify patients who require laparotomy could reduce the laparotomy rate in children with blunt abdominal trauma in these countries. PATIENTS/METHODS: This is a review of children aged 15 years or below managed in our institution over a 5 1/2-year period for blunt abdominal trauma. The children were divided into two groups. Group A consisted of children managed from January 1999 - December 2000. During this period, there was no protocol. Group B consisted of children managed from January 2001 - June 2004. During this period, a simple management protocol was introduced. The laparotomy rates in the two groups were analysed using a simple chi-square. RESULTS: A total of 48 children, representing 63 % of children with abdominal trauma during the study period, were examined (Group A 17; Group B 31). Their ages ranged from 1.5 years - 15 years (median 9 years). Thirty-four were boys, 14 were girls (M:F = 2.4:1). Road traffic accidents accounted for 38 (79.1 %) and falls from heights for 9 cases (18.75 %), and one boy with a hydronephrotic kidney fell off the staircase at home. The diagnosis was clinical, supported by abdominal ultrasound scan (USS) and plain abdominal film. Twenty-eight (58.3 %) children had laparotomy (15 in Group A; 13 in Group B). There was a statistically significant difference in the laparotomy rates between Group A and B (p < 0.01). Nineteen children were managed nonoperatively (2 in Group A; 17 in Group B); one child died before an operation could be performed. There were 59 abdominal organ injuries in 45 children. In 2 children, ultrasound could not diagnose any organ injury. There were 33 splenic injuries; 15 children had splenic conservation, 7 underwent a splenectomy, while 10 were managed nonoperatively. One child with splenic injury died before operation. Of 7 liver injuries, 4 required suturing of lacerations, 1 subcapsular haematoma was left undisturbed at laparotomy, while 2 were managed nonoperatively. There were 4 pancreatic injuries. Three were managed nonoperatively, while 1 associated with duodenal injury had a laparotomy. All 6 gastrointestinal injuries had laparotomy. There were 5 renal injuries: 3 had laparotomy with suturing, while 2 were managed nonoperatively. There were 4 bladder injuries: 2 had laparotomy with suprapubic catheter insertion, while 2 were managed nonoperatively. There were 7 retroperitoneal haematomas in association with other organ injuries. Associated injuries included head injury in 2, long bone fracture in 2, spinal injury and chest trauma in 1 each. There were 4 deaths, 1 before surgery could be performed. CONCLUSION: Blunt abdominal trauma in children resulted mainly from road traffic accidents. The use of a simple protocol supported by ultrasound scan could reduce the laparotomy rate in countries with limited facilities.     

Emergency department evaluation and management of blunt abdominal trauma in children

PURPOSE OF REVIEW: To discuss the emergency department evaluation and management of children with blunt abdominal trauma. The review will focus on both the clinical data that can help reduce the use of computed tomography in the evaluation of patients with blunt abdominal trauma and the evidence for the increased use of nonoperative management of patients with blunt abdominal trauma. RECENT FINDINGS: We will examine the recent literature focusing on the utility of physical examination, laboratory data and imaging (both ultrasonography and computed tomography) in detecting intraabdominal injury. SUMMARY: Recent research suggests that physical examination in combination with bedside ultrasonography may identify children at risk for intraabdominal injury. Screening laboratory data appears to be less sensitive to detect these injuries, but is useful in selected patients. Nonoperative management is appropriate in a majority of cases. Further research is needed to determine which low-risk patients with abdominal trauma can be managed with minimal or no exposure to radiation in the computed tomography scanner.     

Pediatric abdominal trauma: evaluation by computed tomography

When indications for immediate laparotomy are not present, CT of the abdomen and pelvis can be used to evaluate pediatric blunt abdominal trauma. During 2-year period, the medical records and abdominal/pelvic CT scans of 100 consecutive pediatric patients who were evaluated for blunt abdominal trauma were retrospectively reviewed. The scans appeared normal for 73 children. Of these children, 30 had severe head injuries and a depressed sensorium. A total of 27 abdominal/pelvic CT scans were interpreted as abnormal. Findings included nine splenic fractures, six renal contusions, nine hepatic lacerations, one duodenal hematoma, one traumatic pancreatitis, four bony injuries, six miscellaneous abnormalities, and one intraperitoneal bleed. Only two of these 27 patients required abdominal surgery. The remaining 25 patients were treated conservatively based upon a stable clinical state and CT delineation of the extent of injury. No mortality resulted. CT is the radiographic examination of choice for hemodynamically stable pediatric patients with blunt abdominal trauma. CT provided a reliable adjunct examination technique when a physical examination could not be performed and a complete history could not be obtained. The extent of abdominal/pelvic injuries is well delineated and can often be followed by diagnostic imaging, usually allowing for conservative therapy.     

Blunt renal injuries in Turkish children: a review of 205 cases

A retrospective analysis of the medical records of 205 children with renal injuries secondary to blunt abdominal trauma is used to make recommendations regarding the initial diagnostic and therapeutic approaches in this type of patient. It was found that the absence of hematuria on initial urinalysis does not exclude a serious renal injury. Thus, following blunt abdominal trauma, all children should undergo imaging procedures to exclude renal injury, whether they have hematuria or not. Ultrasound is a good initial screening procedure in all patients. Computed tomography is recommended for the definitive evaluation of suspected major renal injuries. Since even major renal injuries may heal without surgical intervention, conservative management is the recommended initial treatment of choice. Surgery is reserved for those children who are hemodynamically unstable and those that develop complications.     

Pediatric trauma score: Is it reliable in predicting mortality?

The Pediatric Trauma Score (PTS) is rapidly gaining acceptance for use in prehospital triage. This study examines its reliability in predicting mortality. The charts of the 533 trauma patients hospitalized between 1984–1989 were reviewed and the PTS was calculated for each. There were 3 deaths in 370 patients with PTS >8, while 24 of 163 children with PTS ⩽8 died. Size categorization was found to be overemphasized because of the low mortality (7.7%) in children smaller than 10 kg, although their mean PTS (6.4 ± 2.1) was significantly lower than the mean PTS (9.0 ± 2.2) of children over 10 kg. Forty-nine of 71 surgically treated patients having intra-abdominal organ injuries had a PTS >8. The existing parameters of PTS did not have equal relationships to mortality, and may even all be inadequate in the correct triage of children with blunt abdominal trauma. Correspondence to: E. Balık     

Blunt abdominal trauma caused by child abuse

We report about 3 boys under 4 years of age with abdominal blunt trauma following child abuse admitted to our clinic with different diagnoses. Common were fresh or older haematomas, burn wounds, for which the parents had no plausible explanation. The children had no skeletal or intracranial lesions, but they developed abdominal pain, which became worse in the absence of the parents. X-ray and the clinical course lead us to laparatomy. In all cases we found lesions of the intestines, especially near the duodenojejunal flexure, hepatoduodenal ligament, root of the mesentery, mesocolon and retroperitoneum, in one case a pancrease rupture. All these lesions were caused by child abuse. We want to point out the problem in the diagnosis of battered child syndrome, especially of the abdominal blunt trauma.     

Hypertension following minor trauma: a rare presentation of pheochromocytoma

The diagnosis of pheochromocytoma (Pheo) can be challenging due to the variety of potential presentations of this infrequent tumor. A 16-year-old boy presented with hypertension and sudden abdominal pain after minor blunt abdominal trauma. Both computer tomography (CT) and magnetic resonance (MR) scanning identified a right suprarenal mass, and raised the possibility of a Pheo. This diagnosis was confirmed through urine catecholamine testing and ¹³¹I metaiodobenzylguanidine (MIBG) scanning. An extra-adrenal Pheo was successfully resected. The presentation of Pheos is quite variable, and patients may often be essentially asymptomatic. Pheo should be considered in hypertensive pediatric patients with a history of blunt abdominal trauma. Accepted: 26 May 1998     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

Complete bronchial rupture in a child: report of a case

Tracheobronchial rupture due to blunt chest trauma is a rare and serious injury in children. The diagnosis is usually difficult and may be overlooked because of the variability of symptoms and findings. Fiberendoscopy is useful in children with stable tracheal or bronchial ruptures. However, in the emergency situation, fiberendoscopy may not be appropriate, and thoracotomy and primary anastomosis may be the best option.     

Isolated traumatic gallbladder rupture: US findings and the role of repeat US in diagnosis

We represent the US findings of isolated gallbladder rupture caused by blunt abdominal trauma in a 13-year-old boy. At the initial US examination, although a pericholecystic fluid collection was observed, the mildly collapsed gallbladder was regarded as a contracted gallbladder. Even though the patient was haemodynamically stable, repeat US examination after 24 h revealed gallbladder perforation. In haemodynamically stable trauma patients repeated US examinations can be useful and are strongly recommended.