Background
Trauma is the leading cause of morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities. Abdominal trauma can be associated with significant morbidity and may have a mortality as high as 8.5%. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children.
Management of abdominal injuries in children has evolved considerably. It has been shown that nonoperative treatment of children with blunt abdominal trauma is successful in more than 95% of appropriately selected cases if trauma care providers have a thorough knowledge of the anatomy and physiology of the growing child. This article reviews the typical presenting signs, evaluation, and treatment of children with suspected abdominal injuries following trauma.
For more information, see Abdominal Vascular Injuries,Penetrating Abdominal Trauma,Blunt Abdominal Trauma and Focused Assessment with Sonography in Trauma (FAST).
For patient education resources, see the Wounds Center, the Trauma Resource Center, and the Children’s Health Center, as well as Puncture Wound and Bruises.
Anatomy
Unique pediatric aspects of the anatomy and physiology of the abdomen contribute to the abdomen’s biomechanical response to traumatic loads.
A young child’s abdomen is square and becomes more rectangular as the child matures. The abdominal wall of a child has thinner musculature than that of an adult, particularly during the first 2 years of life, providing less protection to underlying structures. The ribs are more flexible in the child, which makes them less likely to fracture. However, this increase in compliance makes them less effective at energy dissipation and, therefore, less effective at protecting the upper abdominal structures (eg, the spleen and the liver). [1, 2, 3]
The solid organs are comparatively larger in the child than in the adult; therefore, more surface area is exposed, making the organ more at risk for injury. A lower fat content and more elastic attachments are typical of the intra-abdominal organs in children. These characteristics reduce the amount of energy absorption and may result in increased motility and vulnerability (eg, kidneys). The child’s spleen has a thicker capsule than that of the adult, yet the spleen is among the most commonly injured solid organs in blunt abdominal trauma.
In the young child, the intestine is not fully attached within the peritoneal cavity (especially the sigmoid and right colon), and this incomplete attachment potentially making it more vulnerable to injury from sudden deceleration or abdominal compression. The bladder extends to the level of the umbilicus at birth and therefore is more exposed to a direct impact to the lower abdomen. With age, the bladder descends to its retropubic position.
The rapid growth of the spine during adolescence influences its anatomy and biomechanical properties, particularly in the lumbar area. [4] In a child with a thin abdominal wall and who is poorly restrained (lap belt only), the fulcrum of a flexion injury would be at the body of the spine, which exposes it to a flexion-distraction injury (Chance fracture).
Etiology
More than 80% of traumatic abdominal injuries in children result from blunt mechanisms; most commonly, they are related to motor vehicle accidents. Abdominal injuries may also result from falls or direct blows to the abdominal wall (eg, handlebar injury; see the image below).
In the United States, firearm injuries are by far the most common cause of penetrating wounds. Other causes of penetrating injuries include stab wounds, impalements, dog bites, and machinery-related accidents.
Epidemiology
Traumatic injuries continue to be the leading cause of death in children, far surpassing other causes in frequency. [5] Abdominal trauma accounts for 8-10% of all trauma admissions to pediatric hospitals. Penetrating injuries are less common in children and account for 8-12% of pediatric abdominal trauma admissions in most trauma centers.
Despite declining national trends in firearm-related injury, gunshot wounds (GSWs) are the most common cause of penetrating injuries in the pediatric age group and represent the leading cause of death in black males aged 15-24 years. [6]
Prognosis
Nonoperative treatment of children with blunt abdominal trauma is successful in more than 95% of appropriately selected cases if trauma care providers have a thorough knowledge of the anatomy and physiology of the growing child.
The abdomen is injured in 25% of children with GSWs; of these wounds, 14% are fatal.
Out of all forms of pediatric abdominal trauma, abdominal trauma secondary to assault or abuse is associated with the highest mortality. [7] Abdominal trauma related to child abuse also carries a particularly high risk of hollow viscus injury.
-
Computed tomography (CT) image of grade IV splenic laceration from auto-pedestrian accident.
-
Computed tomography (CT) image of grade IV renal laceration from handlebar injury. Reprinted with permission from Pryor JP, Stafford PW, Nance ML. Severe blunt hepatic trauma in children. J Pediatr Surg, 36:7, 2001, Elsevier Science.
-
Computed tomography (CT) image of grade V liver laceration in unrestrained passenger in motor vehicle accident.
-
Computed tomography (CT) image of duodenal hematoma from blow to abdomen. (Large arrow, hematoma; small arrow, lumen of duodenum.)
-
Abdominal wall findings from handlebar injury.
-
Abdominal wall findings in passenger who was restrained with only lap belt during motor vehicle accident.
-
Penetrating injury to abdomen from shotgun wound.
-
Volume management algorithm for pediatric trauma patient.
Tables
| Frequency of Organ Injury | Blunt | Penetrating |
| Liver | 15% | 22% |
| Spleen | 27% | 9% |
| Pancreas | 2% | 6% |
| Kidney | 27% | 9% |
| Stomach | 1% | 10% |
| Duodenum | 3% | 4% |
| Small bowel | 6% | 18% |
| Colon | 2% | 16% |
| Other | 17% | 6% |
| Grade of Injury | ICU Stay | Ward Stay | House Arrest | Contact Activity Restriction |
| Grade I | None | 1 d | 1 wk | 1 mo |
| Grade II | None | 2 d | 2 wk | 2 mo |
| Grade III and above | 1 d | 3 d | 3 wk | 3 mo |
| ICU – Intensive care unit. |
| Treatment | CT Grade | |||
| I | II | III | IV | |
| ICU stay (d) | None | None | None | 1 |
| Hospital stay (d) | 2 | 3 | 4 | 5 |
| Predischarge imaging | None | None | None | None |
| Postdischarge imaging | None | None | None | None |
| Activity restriction (wk)* | 3 | 4 | 5 | 6 |
|
*Return to full-contact competitive sports (eg, football, wrestling, hockey, lacrosse, mountain climbing) should be at the discretion of the individual pediatric trauma surgeon. The proposed guidelines for return to unrestricted activity include typical age-appropriate activities.
APSA—American Pediatric Surgical Association; CT—computed tomography; ICU—intensive care unit. |
