Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes

Background

Children involved in motor vehicle crashes (MVC) can sustain bruising of the abdominal wall associated with seat belt restraint. The incidence of bruising and its relationship with significant intraabdominal injuries are not known.

Methods

An analysis of children involved in MVC between December 1998 and November 2002 was performed, using the crash surveillance database from the Partners for Child Passenger Safety (PCPS) project. Optimally (OR) or suboptimally (S-OR) restrained children aged 4 to 15 years were selected. The incidence of abdominal wall bruising was calculated then correlated with the type of restraint as well as any intraabdominal injury with an Abbreviated Injury Scale score ≥2.

Results

A total of 147,985 children in 102,548 crashes met study criteria. An abdominal bruise was noted in 1.33% of the children (n = 1,967; 881 OR and 1,086 S-OR). Significant intraabdominal injury was present in 309 children (0.21%, 95% CI 0.13 to 0.33), including 69 OR and 240 S-OR. The sensitivity, specificity, and positive and negative predictive values of abdominal wall bruising for a significant intraabdominal injury were 73.5%, 98.8%, 11.5%, and 99.9%, respectively. Children with a bruise were substantially more likely to have an intraabdominal injury than children without a bruise. (Odds Ratio 232.1, 95% CI, 75.9 to 710.3) Among those children with an abdominal bruise, 1% required an abdominal operation (n = 20).

Conclusions

Abdominal wall bruising was relatively uncommon in both OR and S-OR children. Among restrained children involved in MVC, those with a bruise were 232 times more likely to have a significant intraabdominal injury when compared with those without a bruise. It is imperative to pursue intraabdominal injury in children with a bruise of the abdominal wall after MVC.     

Traumatic aortic injuries in the pediatric population

Background/Purpose

Blunt trauma is the leading cause of pediatric injury, but pediatric aortic injuries are rare. We undertook this study to investigate the demographics, treatment, and outcomes of children with blunt aortic injuries and report our experience over a 10-year period.

Methods

After Institutional Review Board approval, a 10-year retrospective review of all pediatric patients admitted with blunt aortic injury was performed. Patient demographics, injury details and severity score (Injury Severity Score), treatment, and outcomes were recorded.

Results

There were 11 children, with ages ranging from 7 to 19 years. The most common mechanism of injury was motor vehicle crashes (8). Initial computed tomography demonstrated all 11 injuries: 7 thoracic aortic (TA) and 4 abdominal aortic (AA) injuries. Associated injuries were common. The TA injuries included 4 transections, 2 intimal flaps, and 1 pseudoaneurysm. Three of these were managed nonoperatively. The AA injuries included 3 intimal flaps and 1 dissection. Three of these were also managed nonoperatively. There were no complications in the 4 children with AA or in the 3 children with TA managed nonoperatively. Complications in the 4 children undergoing operative repair of the TA included paraplegia, renal failure, recurrent laryngeal nerve injury, and pulmonary embolus. The mean hospital stay was 8 days. All children survived, with all but one discharged directly to home.

Conclusions

Blunt aortic injury in children is uncommon and is primarily associated with motor vehicle crashes. Injuries to the abdominal aorta were seen with restrained children vs those to the thoracic aorta that were seen in children who were unrestrained.     

Patterns of severe injury in pediatric car crash victims: Crash Injury Research Engineering Network database

Background/Purpose

Motor vehicle crashes (MVCs) account for 50% of pediatric trauma. Safety improvements are typically tested with child crash dummies using an in vitro model. The Crash Injury Research Engineering Network (CIREN) provides an in vivo validation process. Previous research suggest that children in lateral crashes or front-seat locations have higher Injury Severity Scale scores and lower Glasgow Coma Scale scores than those in frontal-impact crashes. However, specific injury patterns and crash characteristics have not been characterized.

Methods

Data were collected from the CIREN multidisciplinary crash reconstruction network (10 pediatric trauma centers). Injuries were examined with regard to crash direction (frontal/lateral), restraint use, seat location, and change in velocity at impact (ΔV). Injuries were limited to Abbreviated Injury Scale (AIS) scores of 3 or higher and included head, thoracic, abdominal, pelvic, spine, and long bone (orthopedic) injuries. Standard age groupings (0-4, 5-9, 10-14, and 15-18 years) were used. Statistical analyses used Fisher's Exact test and multiple logistic regressions.

Results

Four hundred seventeen MVCs with 2500 injuries were analyzed (males = 219, females = 198). Controlling for ΔV and age, children in lateral-impact crashes (n = 232) were significantly more likely to suffer severe injuries to the head and thorax as compared with children in frontal crashes (n = 185), who were more likely to suffer severe spine and orthopedic injuries. Children in a front-seat (n = 236) vs those in a back-seat (n = 169) position had more injuries to the thoracic (27% vs 17%), abdominal (21% vs 13%), pelvic (11% vs 1%), and orthopedic (28% vs 10%) regions (P < .05 for all). Seat belts were protective for pelvic (5% vs 12% unbelted) and orthopedic (15% vs 40%) injuries (odds ratio = 3, P < .01 for both).

Conclusion

A reproducible pattern of injury is noted for children involved in lateral-impact crashes characterized by head and chest injuries. The Injury Severity Scale scores were higher for children in front-seat positions. Increased lateral-impact safety measures such as mandatory side curtain airbags may decrease morbidity. Furthermore, continued public education for positioning children in the back seat of cars is warranted.     

Injury patterns among obese children involved in motor vehicle collisions

Purpose

The purpose of this study was to compare injury patterns among obese children to their nonobese counterparts involved in motor vehicle collisions.

Methods

A nationwide data collection program containing occupant, collision, and injury details from police-reported tow-away crashes between 1997 and 2006 were used. Risk ratios (RRs) and associated 95% confidence intervals (CIs) were adjusted for age, sex, restraint, seat track position, vehicle curb weight, and total velocity change.

Results

An estimated 9 million children aged 2 to 17 years (20.2% obese) were involved in motor vehicle collisions during the study period. Among 2-to-5-year-olds, obesity increased the risk of severe head (RR, 3.67; 95% CI, 1.03-13.08) and thoracic (2.27; 1.01-5.08) injuries. Among 6-to-9-year-olds, obesity increased risk of thoracic (2.31; 1.08-4.95) and lower extremity (LE) injuries (1.89; 1.03-3.47). Among 10-to-13-year-olds, obesity increased the risk of severe thoracic (1.98; 1.08-3.65) and LE (6.06; 2.23-16.44) injuries. Among 14-to-17-year-olds, obesity increased risk of severe LE injuries (1.44; 1.04-2.00) but decreased risk of abdominal (0.20; 0.07-0.60) and head (0.33; 0.18-0.60) injuries, very similar to the pattern reported in obese adults.

Conclusion

The pattern of obesity-associated injuries changes from a higher risk of head and thoracic injuries among young children to a pattern in late teenagers that is similar to obese adults.     

Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes

BACKGROUND: The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated. METHODS: Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10927 crashes involving 17132 restrained children, representing 210926 children in 136734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale >or=2 severity. RESULTS: Among all restrained children, optimal was noted in 59% (n = 120473) and suboptimal in 41% (n = 83555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87-6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds. CONCLUSIONS: Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.     

Crashes involving motorised rickshaws in urban India: characteristics and injury patterns

Introduction

Motorised three-wheeled vehicles (motorised rickshaw) are popular in Asian countries including India. This study aims to describe the crash characteristics and injury patterns for motorised rickshaw occupants and the road users hit-by-motorised rickshaw in urban India.

Methods

Consecutive cases of road traffic crashes involving motorised rickshaw, irrespective of injury severity, whether alive or dead, presenting to the emergency departments of two large government hospitals and three branches of a private hospital in Hyderabad city were recruited. Crash characteristics, details of injuries, injury severity parameters and outcome were documented in detailed interviews.

Results

A total of 139 (18%) of the 781 participants recruited were injured as a motorised rickshaw occupant (11%) or were hit by a motorised rickshaw (7%) in 114 crashes involving motorised rickshaw. Amongst motorised rickshaw occupants, single-vehicle collisions (54%) were more frequent than multi-vehicle collisions (46%), with overturning of motorised rickshaw in 73% of the single-vehicle collisions. Mortality (12%), the mean Injury Severity Score (5.8) and rate of multiple injured (60%) indicated a substantial trauma load. No significant differences in injury pattern were found between motorised rickshaw occupants and hit-by-motorised rickshaw subjects, with the pattern being similar to that of the pedestrians and two-wheeled vehicle users. With bivariate analysis for motorised rickshaw occupants, the risk of fatal outcome (odds ratio (OR) 2.60, 95% confidence interval (CI): 0.64-10.54), upper limb injury (OR 2.25, 95% CI: 0.94-5.37) and multiple injuries (OR 2.03, 95% CI 0.85-4.83) was high, although not statistically significant in multi-motorised-vehicle collisions as compared with the single-vehicle collisions or overturning. The risk of having multiple injuries (OR 4.55, 95% CI: 1.15-17.95) was significantly higher in motorised rickshaw occupants involved in front collisions. Being a front-seat motorised rickshaw passenger in a vehicle collision increased the risk of having a fatal outcome (OR 7.37, 95% CI: 0.83-65.66) and a Glasgow coma score ≤ 12 (OR 2.21, 95% CI: 0.49-9.89), although not significantly when compared to the back-seat passengers.

Conclusion

These findings can assist with planning to deal with the consequences and prevention of road traffic injuries due to crashes involving motorised rickshaw, given the high use of these and substantial morbidity of related injuries in India. The need for improved understanding of the risk characteristics of motorised rickshaw is highlighted.     

Alarming trends in the improper use of motor vehicle restraints in children: implications for public policy and the development of race-based strategies for improving compliance

Purpose

Little is known regarding the patterns of appropriate restraint use among minority children involved in motor vehicle collisions. The purpose of this study was to characterize patterns of restraint use among children hospitalized after motor vehicle collision and to examine the effects of race and socioeconomic status on compliance.

Methods

All children admitted to our level I trauma center over a 10-year period were identified. Patterns of appropriate restraint use were compared between African American (AA) and white children. Compliance was also compared between children insured with Medicaid (as a surrogate for socioeconomic status) and those with private insurance coverage.

Results

One thousand two hundred sixty-eight patients were included with an overall restraint use of 44.8% with only 20.3% restrained properly. Compared with white children, AAs were significantly less likely to be properly restrained (12.7% vs 22.2%, P < .001) or to be restrained by any means (28.8% vs 48.7%, P < .001). The greatest disparity between groups was observed in the use of car seats (16.0% vs 47.4%, P < .001). Medicaid patients were less likely to be restrained compared with those with commercial insurance (40.6% vs 48.3%, P = .022); however, race remained a significant predictor of noncompliance after controlling for the effect of insurance status.

Conclusions

These data demonstrate an alarming trend because nearly 80% of all children in our study were improperly restrained. Marked disparities in compliance were observed in the AA population even after controlling for insurance coverage. Future studies will need to further characterize the complex interplay between race and socioeconomic status with proper restraint use.     

Causes of scapula fractures differ from other shoulder injuries in occupants seriously injured during motor vehicle crashes

Purpose

Current motor vehicle safety systems primarily focus on preventing life-threatening and serious injury during crashes, but occupants may still sustain less serious injury. Upper extremity injury is common in occupants involved in motor vehicle crashes. The purpose of this study was to compare occupants with scapula fractures to occupants with other shoulder injuries.

Methods

We used data from the Crash Injury Research and Engineering Network (CIREN) database (1997-2008) to compare two groups of occupants: (1) occupants with only scapula fractures and (2) occupants with shoulder injury not involving the scapula. We hypothesised that there were no differences in demographics, vehicle, crash characteristics and causes of shoulder injury in these two groups.

Results

Of the 3370 occupants studied, 54 occupants (1.6%) had only a scapula fracture in the shoulder region and 342 (10.1%) occupants had other shoulder injuries. There were significant differences between gender, height and weight, maximum Abbreviated Injury Scale (AIS) severity and the crash type. Occupants with scapula fractures were 3 times more likely to be male (odds ratio (OR) = 3.30) and were significantly taller and weighed more than occupants with other shoulder injuries. Occupants with other shoulder injuries had significantly greater injury severity (based on maximum AIS for any injury) than those with scapula fractures. There was a significant difference between scapula fractures and clavicle fractures (OR = 1.87) and joint dislocations/separations (OR = 2.79) comparing the cause of injury (vehicle side interior vs. other causes). Safety belts are the single most important safety system in motor vehicles and should always be worn. However, we found no differences in the cause of scapula fractures comparing occupants wearing their safety belt with those not wearing the belt.

Conclusion

This study provides information showing that scapula fractures occur during different types of impacts and have different causes other than shoulder injuries.     

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

Background

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

Methods

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

Results

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

Conclusions

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.     

Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma

Introduction

Computed tomographic (CT) scans have become invaluable in the management of patients with blunt abdominal trauma. No clear consensus exists on its role in hollow viscus injuries (HVI) and mesenteric injuries (MI). The aim of this study was to correlate operative findings of HVI and MI to findings on pre-operative CT.

Methods

All patients treated for blunt abdominal trauma at Tan Tock Seng Hospital from January 2003 to January 2008 were reviewed. CT scans were only performed if the patients were haemodynamically stable and indicated. All scans were performed with intravenous contrast using a 4-slice CT scanner from 2003 to December 2004 and a 64-slice CT scanner from January 2005 onwards. All cases with documented HVI/MI that underwent both CT scans and exploratory laparotomy were analysed.

Results

Thirty-one patients formed the study group, with median age of 40 (range, 22-65) years and a significant male (83.9%) predominance. Vehicular-related incidents accounted for 67.7% of the injuries and the median Injury Severity Score (ISS) was 13 (4-50).The 2 commonest findings on CT scans were extra-luminal gas (35.5%) and free fluid without significant solid organ injuries (93.5%). During exploratory laparotomy, perforation of hollow viscus (51.6%) occurred more frequently than suspected from the initial CT findings of extra-luminal gas. Other notable findings included haemoperitoneum (64.5%), and mesenteric tears (67.7%). None of our patients with HVI and MI had a normal pre-operative CT scan.

Conclusion

Our study suggests that patients with surgically confirmed HVI and MI found at laparotomy were very likely to have an abnormal pre-operative CT scan. Unexplained free fluid was a very common finding in blunt HVI/MI and is one major indication to consider exploratory laparotomy.     

Incidence and risk factors of non-fatal injuries in Chinese children aged 0-6 years: A case-control study

Aim

To identify the incidence and related risk factors of injuries in pre-school children aged 0-6 years in China.

Methods

Children with non-fatal injuries (n = 122) were matched to healthy controls by sex, age, community of residency and history of injury. Conditional multiple logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs).

Results

The overall incidence of injuries was 3.3%. After adjustment for all selected variables, the risk factors for childhood injuries included father's occupation as a self-employed person (OR: 5.7, 95% CI: 1.8-18.5), child's active temperament type (OR: 2.8, 95% CI: 1.5-5.3), inappropriate storage of medicines (OR: 3.1, 95% CI: 1.3-6.9) and inappropriate placement of heating equipments (OR: 2.1, 95% CI: 1.0-4.4). The protective factors included children's acquirements of safety education from their teachers at school (OR: 0.03, 95% CI: 0.01-0.2), and from their parents (OR: 0.08, 95% CI: 0.02-0.3).

Conclusions

Interventions targeting the risk factors specifically may help prevent and reduce the occurrence of injuries in young children.     

Exhaust system burn injuries in children

Background/Purpose

The authors had noted a number of children who had sustained burn injuries from the exhaust systems of recreational vehicles and wished to document the incidence of pediatric burn injury sustained from the exhaust systems of a wide scope of motorized vehicles.

Methods

The authors conducted a 10-year retrospective chart review including all children admitted to our institution with burn injuries from contact with vehicular exhaust systems.

Results

Twenty-three children were included. There were 18 boys, with a median patient age of 7 years. Most children (7 of 23) were injured from the exhaust systems of all-terrain vehicles. The average burn size (5%) was small, but almost two thirds of the burn injuries were full thickness. Of the 23 children, 21 required operative intervention for their burns, with 2 children requiring multiple surgical interventions. The average length of hospital stay was 11 days, and all children, except one who went to a rehabilitation facility, were discharged to home.

Conclusions

Pediatric health care providers should be aware that exhaust system contact burns in children are not rare events and they do tend to be significant. Surgical consultation should be requested early in the management of these particular burn injuries in children.     

Risk factors for blunt thoracic aortic injury in children

Background/Purpose

Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children.

Methods

Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods.

Results

Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of ≥3) involving the head, thorax (other than aorta), abdomen, and lower extremities.

Conclusions

Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.     

Factors influencing pediatric Injury Severity Score and Glasgow Coma Scale in pediatric automobile crashes: results from the Crash Injury Research Engineering Network

Background/Purpose

Motor vehicle crashes account for more than 50% of pediatric injuries. Triage of pediatric patients to appropriate centers can be based on the crash/injury characteristics. Pediatric motor vehicle crash/injury characteristics can be determined from an in vitro laboratory using child crash dummies. However, to date, no detailed data with respect to outcomes and crash mechanism have been presented with a pediatric in vivo model.

Methods

The Crash Injury Research Engineering Network is comprised of 10 level 1 trauma centers. Crashes were examined with regard to age, crash severity (ΔV), crash direction, restraint use, and airbag deployment. Multiple logistic regression analysis was performed with Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) as outcomes. Standard age groupings (0-4, 5-9, 10-14, and 15-18) were used. The database is biases toward a survivor population with few fatalities.

Results

Four hundred sixty-one motor vehicle crashes with 2500 injuries were analyzed (242 boys, 219 girls). Irrespective of age, ΔV > 30 mph resulted in increased ISS and decreased GCS (eg, for 0-4 years, ΔV < 30: ISS = 10, GCS = 13.5 vs ΔV > 30: ISS = 19.5, GCS = 10.6; P < .007, < .002, respectively). Controlling for ΔV, children in lateral crashes had increased ISS and decreased GCS versus those in frontal crashes. Airbag deployment was protective for children 15 to 18 years old and resulted in a lower ISS and higher GCS (odds ratio, 2.1; 95% confidence interval, 0.9-4.6). Front-seat passengers suffered more severe (ISS > 15) injuries than did backseat passengers (odds ratio, 1.7; 95% confidence interval, 0.7-3.4). A trend was noted for children younger than 12 years sitting in the front seat to have increased ISS and decreased GCS with airbag deployment but was limited by case number.

Conclusion

A reproducible pattern of increased ISS and lower GCS characterized by high severity, lateral crashes in children was noted. Further analysis of the specific injuries as a function and the crash characteristic can help guide management and prevention strategies.     

Posttraumatic small bowel obstruction in children

Background

The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience.

Methods

Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied.

Results

All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative.

Conclusions

Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.     

Incidence and pattern of bear maul injuries in Kashmir

Background

Injuries due to mauling by bears are rarely reported in the literature. The high incidence of such injuries in Kashmir, India, which is a valley surrounded by dense forests and is a habitat of Asiatic Black bears, urged us to undertake such a study in our department.

Materials and methods

The study was conducted both retrospectively (January 1990-July 2005) and prospectively (August 2005-December 2007).

Results

A total of 417 cases were recorded and all the injuries were caused by black bears alone. Majority of the patients were young to middle-aged (96.8% of cases) and predominantly males (80.33%). The incidence was highest during July to November (76.82%), and most of the attacks (97%) occurred during daytime. Soft-tissue injury occurred in all 417 cases, bones were involved in 131 (31.41%) while the visceral organs were injured in four (12.94%) patients. The face (80.57%) was most common part of the body injured, followed by the head (54.67%), and all the patients had soft-tissue injury (100%). In spite of devastating injuries caused by bear maulings, the mortality rate was only 2.39%.

Conclusion

Injuries due to mauling by black bear occur mainly between July and November. The young and middle-aged men have a higher tendency to be wounded. The face and head were the most commonly affected sites, while visceral injuries were rare. Mortality was low, and reconstruction of many of the injuries was challenging, often necessitating a staged procedure. Those living in villages close to black bear habitats may benefit from education related to the risk and severity of the attacks in the hope of reducing the number of injuries seen.     

Camel-related injuries in the pediatric age group

Background

Road traffic accidents continue to be a major cause of morbidity and mortality among children. Domestic animal-related injuries in general, camel-related in particular, have not been given much attention, and very little is written about them.

Methods

The medical records of all children admitted to our hospital with camel-related injuries were retrospectively reviewed for age, sex, mechanism of injury, type of injuries, treatment, and outcome.

Results

Seventy-eight children with camel-related injuries were seen at our hospital. Most of them were camel jockeys. All were males, and their ages ranged from 4 to 15 years (mean, 8.6 years). In 74, the cause of injury was a fall from a racing camel, 2 were kicked by a camel, and 1 had a camel bite. Forty-four (56.4%) had head injury, which was moderate to severe in 17, and 6 of them had associated skull fractures, whereas 3 had intracranial hematomas. Twenty-five (32.1%) had fractures of various bones, and 14 of them had fracture of the tibia. One child had L2 and L3 dislocation, with displacement and compression fracture of L2. Two sustained thoracic injuries, whereas 9 had intraabdominal injuries, including liver injury (3), splenic injury (1), renal injury (3), and bowel injury (2). One had a camel bite leading to a fractured mandible, injury to his ear, and intimal tear of the left common carotid artery.

Conclusions

Camels are a potential cause of serious injuries and a major public health problem for children in this part of the world. This is especially so for camel jockeys. Every effort should be made to prevent such injuries, including limiting camel racing to older children as well as providing adequate protective measures and public education about the proper and compassionate handling of domestic animals.     

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

Purpose

Abdominal wall bruising (AWB) is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC) and is highly suspicious but not indicative of intestinal injury. The aim of this study was to find objective clinical and radiologic predictors for the need of an abdominal exploration in these children.

Materials and Methods

A retrospective chart review of children admitted from 1998 and 2008 with AWB after MVC was conducted. Demographics, vital signs, physical examinations, radiologic investigations, associated injuries, management, and outcome were extracted. Univariate and multivariate statistical analyses were done.

Results

Fifty-three children with a median age of 9 years (range, 3-16 years) were included. Forty-four patients (83%) had abdominal pain on arrival, and 25 (47%) had free intraabdominal fluid on ultrasound/scan. Intraabdominal injuries were noted in 29 patients (55%), and the most common were mesenteric or bowel injuries (25%), splenic injuries (13%), and hepatic injuries (8%). Ten patients (19%) needed therapeutic laparotomy, and all were victims from collision involving 2 moving vehicles, had abdominal pain, free intraabdominal fluid, and tachycardia. Five patients (50%) operated on had lumbar fracture compared to only 4 patients (9%) in the nonoperative group. Pulse rate higher than 120 (P = .048), lumbar fracture (P = .008), and free intraabdominal fluid (P ≤ .001) were significant predictors for intestinal perforation. Overall survival was 98% with 1 death because of head trauma.

Conclusion

Intraabdominal injuries in children with AWB after MVC are frequent. Associated lumbar fracture, the presence of free intraabdominal fluid, and pulse rate higher than 120 are significant predictors of intestinal injuries. An abdominal exploration should be considered in these patients.     

Experience with aortic grafting during excision of large abdominal neuroblastomas in children

Background

Total or near total resection of high-risk, stage 4 abdominal neuroblastoma has been correlated with improved local control and overall survival but may be complicated by vascular injury. We describe our experience in the management of significant aortic injuries during this procedure.

Methods

With the institutional review board waiver, medical records of children who had major abdominal aortic reconstruction during neuroblastoma resection from 1996 to 2006 were retrospectively reviewed.

Results

There were 5 children with aortic grafting: 3 girls and 2 boys. Mean age at surgery was 7.2 years (range, 16 months to 17 years). Two children were operated on for recurrent retroperitoneal disease. Tumor encasement of the aorta was seen in all children. In 3 children, the injury occurred during dissection of paraaortic and interaortocaval lymph nodes below the level of the renal arteries. In the remaining 2 children, injury occurred early during mobilization of the tumor. Three polytetrafluoroethylene tube grafts and 1 on-lay patch graft were used to repair the 4 distal aortic injuries. One 4-year-old female with aortic and renal arterial injuries was managed with an aortic Dacron tube graft and a polytetrafluoroethylene tube graft for the renal artery. The mean period of follow-up is 28 months after aortic graft (range, 3 months to 10 years). Total colonic ischaemia, transient acute tubular necrosis, and duodenal perforation were seen in one child, who needed subtotal colectomy and ileostomy. Another child with an omental patch over the graft had a transient duodenal obstruction, which was managed conservatively. There were no other complications, and 4 of the 5 children are disease-free to date. One child at 10 years after his distal aortic tube graft remained asymptomatic with normal distal blood flow on magnetic resonance angiogram and with normal growth.

Conclusion

The neuroblastoma surgeon should be prepared to perform aortic and vascular reconstruction. Aortic encasement, preoperative radiation therapy, and reoperative surgery were observed in these patients and may be risk factors.