Thoracoabdominal Trauma

Major blunt and penetrating thoracoabdominal injury (injury involving the chest and abdomen) is uncommon in the infant; thus, imaging strategies are the most critical for toddlers and older children. In a child who has suffered massive trauma, protocols similar to those used for accidental injury apply. Initial roentgenograms (x-rays) in the emergency department include a chest x-ray to evaluate for flail chest (loss of stability of the rib cage following fracture of the breast bone or ribs), pneumothorax (air or gas inside the pleural cavity), pleural effusion (fluid in the pleural cavity), and pulmonary parenchymal injury (damage to the lung tissue). Abdominal x-rays are not good indicators of injury to the viscera (solid internal organs), but they will show gross pelvic fractures. A lateral (sideways view) x-ray of the cervical spine should be obtained before further diagnostic studies are performed.

When the patient has been stabilized, examination by CT is indicated. CT is the most effective and sensitive imaging technique for identifying injuries of the lungs, pleura, and solid abdominal organs. It is particularly good for assessing pancreatic injury and duodenal hematomas (blood clots in the upper part of the small intestine), two characteristic findings in abused children.

In children less than 1 year of age, ultrasonography may be a reasonable preliminary study to perform if abdominal injury is suspected. Ultrasonography is an acceptable initial procedure in a child who shows lesser signs of injury or a constellation of nonspecific abdominal signs and symptoms that cannot be explained by the history or a unifying diagnosis. It is also a reasonable examination to perform to diagnose occult (hidden) duodenal hematomas and injuries to the pancreas and kidneys. The diagnosis of duodenal hematoma, particularly if chronic, may be difficult with ultrasonography or CT. On occasion, x-rays of the upper gastrointestinal tract may be required to delineate the injury. Radionuclide (a radioactive material used in imaging) scintigraphy plays a relatively small role in the diagnosis of visceral injury, but it is of value in cases of renal (kidney) contusion and myoglobinuria (blood products in the urine due to muscle injury).