INFLICTED ABDOMINAL-THORACIC TRAUMA

KENT P. HYMEL, MD, LT COL, USAF MEDICAL CORPS
USAF MEDICAL CONSULTANT FOR CHILD ABUSE
Department of Pediatrics
Uniformed Services University
Bethesda, MD
 

  1. Pediatric Blunt Chest and Abdominal Trauma
    1. Inflicted Abdominal-Thoracic Trauma in Children
    1. Relatively uncommon
    2. Second leading cause of fatal child abuse
    3. Present in 0.5% to 8% of physically abused children
    4. 40-50% mortality rate
    5. Nonfatal injuries may be more common than previously reported
    1. 40-50% Mortality Rate
    1. Delay in presentation for medical treatment
    2. Inaccurate or misleading history
    3. Lack of obvious external injury
    4. Low clinical index of suspicion
    5. Unique anatomical and physiologic features of children
    1. Smaller blood volume
    2. Proportionately larger size of pediatric organs
    3. Relatively smaller abdomen and thorax
    4. Close proximity of major organs
    5. Less well-developed abdominal and thoracic musculature and fat
    6. Flexible cartilaginous ribs
    1. Inflicted Abdominal Trauma
    1. Majority of injuries represent blunt trauma, such as a punch or kick
    2. A direct blow to the abdomen may…
    1. Crush organs against the vertebral column or lower rib cage
    2. Compress hollow visceral organs, leading to sudden overdistension and rupture (particularly shortly after a meal)
    1. Penetrating injuries are less common, except in urban settings
    2. With rapid deceleration of the body, internal partially-mobile organs continue in motion with resultant mesenteric shearing or tearing
    3. Compared to accidental abdominal trauma…
    1. Multiple solid organ injury is more common
    2. Hollow viscous injuries are more common
    3. Kidney and spleen injuries are less common
    1. Clinical presentations (in descending order of frequency)
      a. Anterior abdominal wall bruises
      b. Ruptured liver or spleen (shock)

      c. Intestinal perforation (peritonitis)

      d. Duodenal hematoma (obstruction)

      e. Ruptured mesenteric vessel (shock)

      f. Pancreatic injury (pain/fever/vomiting)

      g. Renal injury (hematuria)
       
  1. Inflicted Thoracic Trauma
    1. Represents 1-8% of traumatic thoracic injuries in childhood
    2. Rib fractures are the most common finding
    1. Represent 5-27% of all abusive fractures
    2. Predominantly posterior; lateral and anterior costochondral fractures less common
    3. If caused by CPR, very rare
    4. Because ribs are compliant, substantial force is required to fracture
    5. Underlying thoracic visceral injury is uncommon but reported
    1. Pneumothorax
    2. Hemothorax
    3. Chylothorax
    4. Pulmonary contusion
    5. Cardiac contusion
    6. Pneumomediastinum (usually secondary to pharyngeal and esophageal perforation)