The imaging of paediatric thoracic trauma

Abstract

Major chest trauma in a child is associated with significant morbidity and mortality. It is most frequently encountered within the context of multisystem injury following high-energy trauma such as a motor vehicle accident. The anatomic-physiologic make-up of children is such that the pattern of ensuing injuries differs from that in their adult counterparts. Pulmonary contusion, pneumothorax, haemothorax and rib fractures are most commonly encountered. Although clinically more serious and potentially life threatening, tracheobronchial tear, aortic rupture and cardiac injuries are seldom observed. The most appropriate imaging algorithm is one tailored to the individual child and is guided by the nature of the traumatic event as well as clinical parameters. Chest radiography remains the first and most important imaging tool in paediatric chest trauma and should be supplemented with US and CT as indicated. Multidetector CT allows for the accurate diagnosis of most traumatic injuries, but should be only used in selected cases as its routine use in all paediatric patients would result in an unacceptably high radiation exposure to a large number of patients without proven clinical benefit. When CT is used, appropriate modifications should be incorporated so as to minimize the radiation dose to the patient whilst preserving diagnostic integrity.

Blunt traumatic bronchial transection in a 28-month-old child

“…[1234] The true incidence of TBI is unknown, but it is probably 0.5-2% among individuals who sustain blunt trauma. [3] Although rare in children, rupture of the central airway is still more common in children than in adults and there are two peaks of incidence: 5-6 years old children tend to be pedestrians involved in traffic accidents and falls at home and 12-14 years old children tend to be involved in motorbike accidents.…”

“…However, CT is presently the noninvasive method of choice for evaluating patients with major chest trauma and can provide useful information without confirmation by bronchoscopy. [2389] In an emergency situation, bronchoscopy may not be appropriate and surgery may be performed depending on the patient's clinical condition. For adequate repair and pulmonary preservation, the surgery should be performed within 48 h.[36] Delayed surgical repair carries a higher risk for infection and stricture formation.…”

“…Bronchial rupture can be difficult to diagnose in children due to its varied clinical signs, and there is often no radiographic or physical evidence of intrathoracic injury in the early post traumatic period and some hospitals do not fit out a fiberoptic bronchoscopy for little children. [12]…”

Penetrating pediatric trauma owing to improper child safety seat use

“…This case illustrates the role of the CT scan in evaluating penetrating injuries to the thorax to define injury in the hemodynamically stable patient with a penetrating thoracic injury [12,13]. Once the primary and secondary surveys have been completed, imaging may be considered if the patient is hemodynamically stable and does not have an indication to go directly to the operating room, as 85% of penetrating thoracic injuries can be managed without thoracotomy [14,15].…”

Paediatric trauma imaging: Why do we need separate guidance?

“…This has already been discussed with regard to cervical spine imaging, but concerning the chest, it should be noted that children have a different thoracic injury pattern to adults as their rib cages are relatively pliable and tend to bend rather than break. 33,34 Aortic and diaphragmatic injury is rare and only accounts for 0.06% of these cases, and 91% of thoracic injuries may be identified on the CT of the abdomen, if the examination is started 1 cm above the dome of the diaphragm. Management is conservative for small pulmonary contusions and pneumothoraces, and a normal plain chest radiograph has been shown to be a sufficiently sensitive examination to identify those injuries that do require intervention.…”