Tracheobronchial rupture in a child following blunt trauma

A 6-year-old boy sustained a crush injury to the upper chest that resulted in a linear laceration of the membranous part of the lower trachea and right main stem bronchus. He presented with extensive subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum. The diagnosis was indicated by a CT scan of the chest and confirmed by bronchoscopy. The trachea was intubated in the operating room after rigid bronchoscopy. Intraoperative leakage of gas from the tracheobronchial laceration was minimized by single left-lung manual ventilation and application of moist packs to the site of tracheal injury. Surgical repair was achieved with interrupted sutures of non-absorbable material; a pedicle pleural flap was used to buttress the suture line. The patient was discharged in good condition after 1 week. Complete healing of the anastomosis was attested at bronchoscopy 2 months postoperatively. The rarity of tracheobronchial lacerations in childhood is noted on review of the literature. Emphasis is placed on early recognition and expeditious management of tracheobronchial lacerations. Rarely, these lacerations have been reported to heal spontaneously.     

Bronchial rupture in children following blunt chest trauma

We present five patients with fracture of the bronchus, in whom the diagnois of bronchial rupture was first suggested because of persistent leakage of air, atelectasis of a segment of the lung or of the entire lung, mediastinal and deep cervical emphysema. In all patients the bronchoscopy was essential to confirm the diagnosis and to determine the full extent of injury.     

Ruptured interventricular septum after blunt chest trauma: Ultrasonographic diagnosis

Summary A 6-year-old child was found under a heavy bookcase that compressed her chest. On admission to the emergency room she was found to be dyspneic with a systolic murmur and complete atrioventricular (A-V) block. Her condition deteriorated rapidly, leading to cardiogenic shock and loss of consciousness. Echocardiographic Doppler evaluation demonstrated a large ventricular septal defect and tricuspid insufficiency. A pericardial patch was put over the tear in the septum, and torn chordae tendinae were reimplanted to the papillary muscles. A pacemaker was inserted. Her situation improved, but on the third day cardiogenic shock and right ventricular dysfunction ensued and the patient expired. A review of the previous 13 cases from the pediatric literature is presented.     

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.     

Pediatric blunt splenic trauma: a comprehensive review

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.     

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     

Postinfarction ventricular septal defect following blunt chest trauma in a 7-year-old child

Blunt cardiac injury may result in traumatic ventricular septal defect (VSD) in the pediatric population, but presence of postinfarction VSD with accompanying coronary artery thrombosis has not been reported in the literature thus far. We present a seven-year-old patient who underwent surgery for posttraumatic VSD closure and bypass grafting of thrombotic left anterior descending coronary artery (LAD) occlusion following blunt chest trauma. A high index of suspicion and early use of the appropriate imaging studies are essential for diagnosis and surgical treatment of this condition.     

Lung contusion-lacerations after blunt thoracic trauma in children

Chest trauma in children is an indicator of injury severity and is associated with a high mortality rate. The aim of this study was to investigate the impact of pulmonary contusion-laceration on short and long-term outcome of pediatric patients after blunt thoracic trauma. A retrospective analysis of records of 41 children aged 10 months to 17 years who were treated for pulmonary and associated injuries between 1986 and 2000 was done concerning mode of injury, types of injuries, management and outcome. In addition, a follow-up investigation was performed 4.5±1 years after injury. Of the patients 27 were involved in motor vehicle accidents (MVA group) and 14 patients suffered other types of accidents (others group). The mean injury severity score (ISS) was 30±2 (range 9–75) with no significant difference between the groups. Patients from the MVA group suffered more frequently bilateral pulmonary lesions and needed more often chest tube placement (p<0.05), 5 patients died (12%) all from the MVA group. The follow-up investigation of 34 patients showed unremarkable chest x-rays and normal lung function in all but 1 patient with bronchial asthma. In conclusion, children who recover after a pulmonary contusion-laceration trauma do not suffer from significant late respiratory problems.     

Unilateral blunt testicular trauma in pre-pubertal rats

Injury to the testis breaching the tunica albuginea is known to affect fertility. Blunt testicular trauma with an intact tunica albuginea has been reported to have no effect on contralateral testicular histology and Johnsen testicular maturation score. However, sensitive techniques like DNA flowcytometry have not been utilized so far to evaluate contralateral testicular germ-cell changes. Sixty-four male Wistar rats aged 20 days were randomized into groups I (control), II (unilateral blunt testicular trauma, UBTT), III (UBTT and excision of ipsilateral testis at 6 h), and IV (UBTT and cyclosporine for 30 days). Fertility, DNA flowcytometry of contralateral testicular tissue, and anti-sperm antibodies (ASA) were evaluated. Fertility and haploid-cell percentage of the contralateral testis were significantly decreased compared to controls in early adulthood (100 days). Around 150 days of age, as ASA decreased significantly, fertility and contralateral testicular haploid-cell population recovered and were comparable to the controls. Excision of the traumatized testicle around 6 h after injury or administration of cyclosporine for 30 days protected fertility and the contralateral testis. In contrast to group II rats, ELISA for ASA was negative in group III and IV rats. UBTT affects the contralateral testis and fertility. ASA mediate this damage. Orchidectomy performed around 6 h after trauma or short-term cyclosporine therapy prevents the damage. Accepted: 5 January 1999     

Diaphragmatic hernia following blunt trauma in a child

Summary A nine-year old boy successfully treated for an acute diaphragmatic hernia resulting from blunt trauma is presented. The clinical features, diagnosis and management of this rare condition are briefly reviewed. From the Main Hospital, Steel Plant, Bhilai (M.P.)     

Splenic abscess following blunt abdominal trauma

A rare case of splenic abscess occurring after blunt abdominal trauma in a previously healthy boy is reported. The diagnosis was made by ultrasonography. The patient recovered after splenectomy and drainage of subphrenic and intraperitoneal pus.     

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.     

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     

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.     

Isolated rupture of an accessory liver from blunt abdominal trauma in childhood

 An accessory liver is uncommonly encountered in surgical practice. It can rarely cause acute abdominal pain. An isolated injury to an accessory liver from blunt trauma in a 10-year-old boy caused major intraperitoneal haemorrhage. Laparotomy and excision of the lacerated accessory liver lobe was necessary; the patient recovered uneventfully. The literature on accessory liver is reviewed. Accepted: 18 December 2000     

Adrenal lacerations in child abuse: a marker of severe trauma

There are few reports of adrenal injuries complicating inflicted pediatric trauma. All child-abuse cases at the New York City Medical Examiner's Office over a 7-year period were reviewed. Of these 121 homicides, 50 sustained severe injuries to the torso. Five infants (10.0%) had adrenal laceration, a marker of major blunt-force injury. Accepted: 21 January 1999     

CT diagnosis of gastric rupture following blunt abdominal trauma in a child

Conclusion Traumatic gastric perforations are uncommon, especially in children. CT may be helpful in establishing an early diagnosis thereby decreasing the period of peritoneal contamination, sepsis and shock. This may also lessen intraperitoneal abscess formation. This case is probably the first which illustrates the CT criteria of gastric perforation.