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Imaging Evaluation of Pediatric Chest Trauma
Sjirk J. Westra, MDa,b,*, E. Christine Wallace, MDc,d
b a Radiology, Harvard Medical School, Boston, MA, USA Department of Radiology, Massachusetts General Hospital, 34 Fruit Street, Boston, MA 02114, USA c Division of Pediatric Radiology, UMassMemorial Medical Center, Worcester, MA, USA d Radiology, University of Massachusetts, Worcester, MA, USA
Thoracic injury is a leading cause of death resulting from trauma in children, second only to head injury [1,2]. Blunt injury is approximately six times as common as penetrating injury . Because the physical examination is limited in children with multitrauma, especially when there is loss of consciousness because of head injury, imaging plays an important role in diagnosis. The supine anteroposterior (AP) chest radiograph performed in the trauma room, limited as it may be by technical factors and artifact from overlying immobilization hardware, remains an important tool for the prompt diagnosis of life-threatening conditions such as a tension pneumothorax. With focused sonography the lower chest and pericardial space can be assessed rapidly for the presence of significant hemothorax or hemopericardium, which require urgent aspiration . Once a severely injured child is stabilized hemodynamically, further imaging tests need to be undertaken to identify internal injury. During the past 2 decades, CT has emerged as the most reliable technique to evaluate chest injury in multitrauma patients, not only in adults [4 – 7], but increasingly in the pediatric population [8,9]. On their 16-detector scanners, the authors use a peak kilovolts (kVp) of 120 to 140 and milliampereseconds (mAs) adjusted to patient weight and age . More recently, they have implemented auto-
* Corresponding author. Department of Radiology, Massachusetts General Hospital, 34 Fruit Street, Boston, MA 02114. E-mail address: firstname.lastname@example.org (S.J. Westra).
matic longitudinal dose adjustment based on the measured attenuation on the scanogram and a preset noise level of 12. Using the shortest available tube rotation time (0.5 seconds) and a table speed of 15 mm/rotation, this protocol allows contiguous slice reconstructions of 5- and 2.5-mm thickness. The 2.5-mm slices are used for generating multiplanar reformatted images from the three-dimensional dataset. All studies preferably are done with CT angiography (ie, use of a power injector, rapid bolus injection, and scan acquisition initiated within 20 seconds after the start of the contrast injection). Chest trauma does not occur in isolation but is often associated with injury to other parts of the body. In fact, the presence of significant chest injury in a multitrauma patient is an indication of the overall severity of the child’s injuries [2,11,12]. The demonstration of clinically silent concomitant chest injury in patients with known head, cervical spine, abdominal, and extremity injury substantially affects the prognosis, especially in children . Diagnostic evaluation of injured children should take into account that significant trauma does not respect anatomic boundaries and may lead to multisystem involvement. On the other hand, one should realize that most pediatric trauma is minor, and children have an amazing capacity to overcome even major injury without residual sequelae. The pediatric body is more flexible, lighter, and proportioned differently than the mature body, leading to unique patterns of injury. Because of their large relative head size, craniofacial injury is more common and can be more severe in young children than in adults, and because
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. the incidence of an unstable flail chest resulting from multiple adjacent rib fractures. the presence of multiple rib fractures signifies a higher-energy impact than in adults . For this reason. (C ) Volume-rendered coronal image of CT scan demonstrates widening of the right sternoclavicular joint (*). leading to thrombotic (T) occlusion and collateral flow (C) to the right neck. because more force is required to break Fig.268 westra & wallace of ligamentous flexibility major cervical spinal cord injury can occur without radiographic abnormalities . In children. imaging protocols that were developed in the adult population do not apply optimally to children of all age groups. because of children’s compact body size and lower weight. For all these reasons. (B ) CT shows a left-sided displaced rib fracture (white arrow ) and a right-sided nondisplaced rib fracture (black arrow ) that was not recognized on the chest radiograph. Seatbelt injuries and injuries to children ejected from a car restraining device or from airbag deployment often have features that are unique and explainable by maladjustment of these devices to the various pediatric body sizes and proportions. as may be encountered in adult chest trauma patients. indicative of joint dislocation. the authors discuss their diagnostic approach to the pediatric multitrauma patient with an emphasis on chest imaging. is comparatively low in children . third. Conversely. Chest wall Rib fractures are less common in children than in adults because of the compliance of the anterior chest wall in children . there are displaced fractures of the left second. extremity injuries from falls are frequently less severe in young children than in adults falling from a similar height. Following a discussion of the various imaging manifestations of pediatric chest trauma by anatomic location. 1. (D ) Note costoclavicular compression (arrows ) of subclavian vein. and fourth ribs (arrows ). (A ) On frontal chest radiograph. Note venous collaterals around right scapula caused by venous thrombosis. Chest wall injury in 18-year-old man who has pelvic fractures resulting from a high-impact motor vehicle collision.
1) . Detection of isolated rib fractures has little clinical significance (with the exception of child abuse). and these are well seen on skeletal surveys.11]. the Fig. radiographic skeletal survey in combination with skeletal scintigraphy continues to be the standard of care for the evaluation of suspected child abuse. As expected. because these fractures do not have specific treatment implications [4. however. (A ) Note widening of the left paraspinal line (arrows ) on frontal chest radiograph. Because of the delay in clinical presentation that is typical in child abuse. Acute nondisplaced rib fractures are best detected with skeletal scintigraphy. Acute nondisplaced rib fractures are notoriously difficult to identify on AP chest radiographs and are more reliably imaged with CT (Fig. For these reasons. lacerations) may occur in the absence of any rib fractures. healing fractures with callus are more prevalent than acute nondisplaced fractures. but a lateral view (not shown) demonstrated mild loss of height of a mid-thoracic vertebral body. especially when supplemented by oblique views. No displaced fracture is recognized on this image. 2. Child abuse: multiple bilateral nonacute posterior and anterior rib fractures. significant lung injury (contusions. the flexible pediatric ribs than to break the more rigid and sometimes osteoporotic ribs of adults. performed in conjunction with cranial MR imaging to detect subdural hematomas. Although considered a sensitive test for acute rib fractures. there is a high association between the occurrence of rib fractures and pneumothorax and hemothorax. and CT is generally not indicated in this setting. 1).imaging pediatric chest trauma 269 Fig. Recently. 3. . Fractures of the upper three ribs signify high-energy impact and are often associated with fractures in the shoulder girdle and vascular injury (Fig. (B ) Coronal reformatted image of multidetector row CT confirms left paraspinal hematoma (arrow ) and demonstrates subtle fracture in mid-thoracic body (arrowhead ). Multiple aligned posterior rib fractures have a well-known association with nonaccidental injury  and presumably result from the leveraging motion of the posterior ribs on the transverse processes during AP chest compression (Fig. This fracture did not involve the spinal canal and was considered stable. 2). Because of the flexibility of the pediatric chest. has been described . a screening fast T2-weighted or inversion-recovery total-body MR imaging examination. Subtle thoracic spine fracture in a 15-year-old boy following a bicycle accident with hyperflexion injury.
and there is a high association with neurologic deficit because of the relatively large size of the thoracic cord with respect to the spinal canal . 5. clinical utility of fast MR imaging in the setting of suspected child abuse has yet to be established. An important sign for subtle thoracic spine fractures is widening of paraspinal lines. indicative of a hematoma (Fig. Sternal and Fig. Right clavicular and bilateral scapular fractures in a 7-year-old boy following a motor vehicle collision. 4). . (B ) Axial CT image demonstrates bilateral minimally displaced fractures in the scapulae (arrows ). Because of the relative stabilization of the thoracic vertebral column by the rib cage. Severe fracture-dislocation in midthoracic spine in a 17-year-old boy who has sustained major injury in a motorbike accident resulting in paraplegia. Most thoracic spine fractures are unstable. 3). and CT is the imaging modality of choice both for initial diagnosis and for assessment of complications of surgical immobilization for vertebral trauma. (A ) Axial and (B ) sagittal images of multidetector-row CT show unstable fracture with focal kyphosis and severe impingement of the spinal canal by bone fragments. 4. displaced fractures and dislocations in the thoracic spine are indicative of a high-energy impact (Fig. Upper thoracic spinal injuries are often poorly demonstrated on AP chest radiographs .270 westra & wallace Fig. (A ) Frontal chest radiograph clearly shows right clavicular fracture (white arrow ). 5). Fracture of the clavicle can be seen as an isolated injury or can be associated with other injuries involving the shoulder girdle (Fig. only the right fracture could be identified—in retrospect— on the frontal chest radiograph (A. black arrow ).
or in association with central air leak from the tracheobronchial tree (pneumomediastinum). The presence of a tension pneumothorax. Anteromedial pleural air collections are visible on chest radiographs as hyperlucency of the affected hemithorax (Fig. and Hounsfield density measurements may help confirm their hemorrhagic nature [4.5]. On supine chest radiography. High-pressure ventilation in the setting of the adult respiratory distress syndrome (ARDS) can lead to iatrogenic pneumothorax. Hemothorax is a result of venous or arterial bleeding into the pleural cavity.11].8. Diagnosis of pneumothorax is straightforward on upright chest radiographs. an unduly sharp heart border or the deep-sulcus and double-diaphragm signs [4.19]. with demonstration of the visceral pleural line outlined by free pleural air in the apex of the chest. Decubitus positioning. Pleura Pneumothorax can result from penetrating injury to the chest wall. 7).9] (Fig. In the multitrauma patient. constitutes an emergency that requires rapid communication with the treatment team [4.11]. but the clinical significance of small pneumothoraces in patients who are not receiving positive-pressure ventilation support is controversial [12. The cross-table lateral view is less sensitive to demonstrate small. (A ) Frontal chest radiograph. posterior sternoclavicular dislocations often lead to severe injury of the upper thoracic vessels and the trachea [4. consistent with an anteromedial pneumothorax. who is typically in the supine position.imaging pediatric chest trauma 271 scapular fractures (Fig. In particular. from air leak into the pleural space from an injured lung (laceration). as evidenced by mass effect. 7). in the case of larger amounts of fluid. and traumatic chylothorax. Tension pneumothoraces can be small and may not exhibit any mass effect. reactive effusion secondary to pulmonary parenchymal injury.9. CT is more sensitive than radiography for demonstrating small effusions (Fig. pleural effusions manifest as a veil-like increased density over the involved hemithorax with preserved visibility of pulmonary vascular markings and. . Expiration films may enhance the visibility of pneumothoraces. which required thoracostomy tube placement. such as intraparenchymal course and associated pulmonary contusion [5. (B ) CT confirms left pneumothorax.9]. 6). especially when occurring bilaterally in a patient receiving positive-pressure ventilation [5. Active contrast extravasation into the pleural space Fig. The differential diagnosis includes infusothorax from a misplaced central venous line.18]. thickening of the lateral pleural line [4. anteriorly located pleural air collections and often cannot determine laterality. 5) are more often seen in high-impact motor vehicle accidents involving a shoulder seatbelt . and these injuries are associated with a high incidence of vascular and cardiac injury [4.7. Note hyperlucency of upper left hemithorax and sharp outline of left upper mediastinum. pneumothorax is more difficult to diagnose and often can be diagnosed only by indirect signs . A small pneumothorax is evident at the apex (arrows ). 6. CT is also superior for accurate assessment of chest tube placement and related complications. CT is more sensitive than chest radiography for small pneumothoraces [2. Note air in left back musculature (arrow ) caused by the stab wound. is often not possible because of the need for patient immobilization.7]. Pneumothorax secondary to penetrating injury in an 18-year-old man who was stabbed in the left posterior chest.9].7].7. as would be optimal to visualize the visceral pleural line.
Pulmonary contusions are commonly found in blunt chest trauma  and are caused by the direct impact of adjacent bony structures such as ribs and spine on the lung parenchyma at the time of the injury. (B ) CT image confirms bilateral pneumothoraces.7. (B ) CT demonstrates the typical peripheral posterior location of pulmonary contusion with a zone of subpleural lucency (arrows ). Air – fluid level in the right pleural space (arrows ) indicates the intrapleural hemorrhagic component of the hemopneumothorax. Pulmonary parenchyma Primary traumatic pulmonary parenchymal lesions include contusion and laceration [4. 8. splenic laceration. leading to focal edema and hemorrhage (Fig. may occasionally be seen in the case of arterial or major (pulmonary) venous injury . 7. and superimposed (hospital-acquired) pneumonia may secondarily affect chest trauma patients and often lead to ARDS. Aspiration. 8). Hemopneumothorax in a blunt chest injury in an 18-year-old man who has multiorgan trauma (renal contusion. Air in the right chest wall is related to chest tube placement. multiple extremity and mandibular fractures).272 westra & wallace Fig. fat embolism. (A ) Frontal chest radiograph shows ill-defined alveolar opacities in the left lung. intubation-related atelectasis.5. . Bilateral chest tubes were placed in the emergency room as part of resuscitation. The free edge of the contused right lung is outlined by pleural air (white arrow ). (A ) Frontal chest radiograph demonstrates deep sulcus sign (dotted arrow ).21]. Pulmonary contusion in a 16-year-old boy who has blunt chest injury following a motor vehicle collision. They can be visible on chest radiographs with some delay of up to 6 hours but are more reliably demonstrated on CT as peripherally located Fig.
they may be indistinguishable from the surrounding contusion. Probable fat embolism in a 16-year-old boy who has open comminuted tibial fracture. and location in the dependent portions of the lung. (A ) Frontal chest radiograph shows bilateral nodular pulmonary opacities. and they typically exhibit a thin zone of surrounding subpleural lucency. 10. Initially. which is more consistent with fat embolism than with contusion or aspiration. Atelectasis and aspiration pneumonia are differentiated from contusion by their segmental distribution. (A ) Frontal chest radiograph shows a round lucency in left paracardiac region (arrow ) and an indistinct left heart border. especially in chil- Fig. they may cross segmental anatomic boundaries and the interlobar fissures.imaging pediatric chest trauma 273 Fig. This lucent zone is thought to represent relatively hypovascular lung tissue that was compressed at the moment of the injury and therefore is relatively spared of bleeding [13. Contusions affecting more than one third of the alveolar air space are associated with an increased requirement for mechanical ventilation [23. (B ) CT image demonstrates the widespread perivascular distribution of these opacities.22]. Pulmonary lacerations tend to heal more slowly than contusions. Because of the disruption of lung tissue. a bronchopleural fistula may develop. When large. and. There was also a small anteromedial pneumothorax (black arrow ) that was not recognized on the chest radiograph but did not require thoracostomy tube placement. or shearing blunt forces to the lung (Fig. 9). but most resolve without scarring within 7 days. one or more air cavities develop over time and may contain a central density or fluid level because of intrapulmonary hematoma. 9. configuration. areas of air-space consolidation without air bronchograms. In the case of large lacerations involving the pleural surface. Pulmonary laceration in an 8-year-old boy who has blunt left upper-abdomen trauma. . (B ) CT confirms lung laceration (white arrow ) surrounded by areas of contusion. such as adjacent displaced rib fractures.24]. Lacerations result from penetrating injuries.
(C ) Axial CT image shows laceration in posterior aspect of right mainstem bronchus (arrow ). Fat embolism (Fig. Bronchial rupture was repaired surgically. obtained because of persistent air leak despite well-functioning chest tubes. Multidetectorrow CT with multiplanar reformatted images and virtual bronchoscopy is an excellent technique to demonstrate the defect and the resulting air leakage Fig. (B ) Corresponding coronal reformation of chest CT. Note also extensive laceration and surrounding contusion in the right lung. 11. Emergency tracheostomy and bilateral chest tube placement were required for initial stabilization. Bronchial rupture in an 18-year-old man following blunt face and upper-chest trauma. and left pneumothorax. a delayed clinical presentation may be encountered .7. (D ) Coronal reconstruction shows interstitial air dissecting medially to the bronchus intermedius (arrow ). Tracheobronchial tree Rupture of the major airways is a life-threatening emergency that can be recognized on chest radio- graphs by severe and persistent pneumomediastinum and pneumothoraces in the presence of well-functioning chest tubes [4. The injury may result from direct involvement by penetrating chest trauma or from a sudden increase in intrathoracic pressure against a closed glottis in blunt chest trauma. demonstrates pneumoperitoneum. (A ) Frontal chest radiograph shows pneumomediastinum and extensive subcutaneous emphysema. subcutaneous air.274 westra & wallace dren. 10) has been described as a cause of geographic ground-glass or diffuse nodular opacity in trauma patients who have sustained major fractures and additionally exhibit petechial skin hemorrhages and neurologic dysfunction . . Particularly in children. pneumomediastinum. they may leave behind a persistent cavity called a posttraumatic pulmonary pseudocyst. The defect typically occurs within 2 cm of the carina.21].5. most commonly in the proximal right mainstem bronchus.
initially with water-soluble contrast material. because it decompresses into the soft tissues of the neck and chest wall (Figs. Detection of a mediastinal hematoma (Fig. Pneumomediastinum can have benign causes and be self-limiting.11]. it results from air entering the mediastinum from another anatomic space. 11) [4. These benign forms of mediastinum generally do not require any follow-up with crosssectional imaging . Esophagram (not shown) did not demonstrate any perforation. Perforation of the esophagus may be caused by penetrating injury from within (a swallowed sharp object) or outside (gunshot wounds with bullet trajectory traversing the posterior mediastinum. because it may be a clue to an occult traumatic aortic injury (TAI). 13) is extremely important. . 11). heart. such as occlusion of the defect or selective bronchial intubation. however. pneumomediastinum generally does not require specific treatment. such as in penetrating neck or chest wall injury. which are temporizing measures before final surgical repair. leading to alveolar rupture.29]. when lifting a heavy object). Benign and self-limiting pneumomediastinum can occur with acute increase in alveolar pressure caused by blunt abdominal trauma together with air outflow obstruction (closed glottis at the time of injury). a well-penetrated AP chest radiograph obtained in the trauma room is used as the first screening for this condition. 12.7.11. generally indicates a highpressure air-leak that warrants further investigation with CT to determine its underlying cause (Fig. If the injury is suspected.27]. Mediastinum. Unexplained pneumomediastinum and pleural effusions are the most important radiologic signs. which remains quite rare in children but is important because of its potential lethality. Benign pneumomediastinum in a 16-year-old boy who has chest pain after blunt injury. 11 and 12) and occasionally into the peritoneal cavity through existing channels in the diaphragm.imaging pediatric chest trauma 275 (Fig. Rarely. followed by barium [5. and great vessels Pneumomediastinum is recognized by streaky air collections outlining mediastinal structures such as the thymus (spinnaker-sail or angel-wing signs) or the superior surface of the diaphragm (continuousdiaphragm sign). Despite its limitations. or it can be a sign of serious trauma. Mediastinal measurement criteria published in the adult Fig.5. Such pneumomediastinum is analogous to benign forms of pneumomediastinum occurring in asthmatic patients with severe air trapping or after straining against a closed glottis (eg. It can be differentiated from an anteromedial pneumothorax by the bilaterality of its findings and its lack of movement with decubitus positioning. No matter the cause. which is often clinically silent [6. an esophagram should be performed. This pneumomediastinum resolved spontaneously. especially in patients requiring positive-pressure ventilation and chest tube placement. Fiberoptic bronchoscopy is required for confirmation while permitting attempts at endoluminal treatment. such as penetrating injury and tracheobronchial and esophageal rupture [7.7]. A pneumomediastinum that ruptures through the parietal pleura to cause a pneumothorax. as judged from the CT scan) . with air dissecting into the peribronchial interstitial tissues toward the mediastinum. (A ) Axial and (B ) coronal CT images show small pneumomediastinum.
rightward displacement of the nasogastric tube (white arrow ).47]. Traditionally. Of greater value is the combination of a compelling clinical history and the more subtle signs of an abnormal mediastinum (regardless of its size).11] and do not necessarily apply to children. aortography has been used to diagnose TAI. Multidetector-row CT angiography and transesophageal echocardiography have emerged in recent years as tests that are helpful to rule out or demonstrate TAI in patients with an abnormal mediastinum on chest radiography [9. blurring of the aortopulmonary window. The most common finding in TAI is a pseudoaneurysm. such as obliterated contour of aortic arch. TAI will be diagnosed in only 10% to 20% of cases. (A ) Frontal chest radiograph shows a widened mediastinum. Traumatic aortic injury in a 17-year-old girl following a high-impact motor vehicle collision. (D ) Volume rendition better shows the relation of the pseudoaneurysm with the left subclavian artery (S). involving the anterior aspect of . especially in hemodynamically unstable patients.25) have been proven to lack a sufficient predictive value for TAI [4.12. Even when a mediastinal hematoma is identified on plain radiography or CT. and downward displacement of the left mainstem bronchus (black arrow ). the hematoma is caused by self-limiting bleeding from smaller vessels for which no specific intervention is required. 13.7. and a left apical pleural cap . deviation of trachea and nasogastic tube to the right. in the remainder. obliteration of normal mediastinal contours. information that was important for the vascular surgeon before successful placement of an endoluminal stent.276 westra & wallace Fig.11. Whereas a normal chest radiograph has a high predictive value to rule out TAI. widening of the paravertebral and paratracheal stripes. mediastinum-to-chest ratio greater than 0. typically located at the level of the left mainstem bronchus. downward depression of the left mainstem bronchus. (B ) Axial image and (C ) oblique-sagittal reconstruction from CT angiogram depict traumatic pseudoaneurysm in proximal descending aorta (arrows ). literature  (mediastinal width greater than 8 cm.5. none of the signs is sufficiently specific for diagnosis .
Diaphragmatic injury in a 14-year-old boy following a stab wound to the left flank. and C and D. The adventitia is the only layer holding the aorta together. white and black arrows.7]. white arrows ) that were surgically confirmed. .31].30. immediately distally to the aortic isthmus. atypical locations may be encountered more com- monly in those who survive long enough to be evaluated with CT . wall irregularities. This pseudoaneurysm is not to be confused with the ductus diverticulum (‘‘ductus bump’’).30]. (B ) Axial CT image and (C ) coronal and (D ) sagittal reconstructions of left hemidiaphragm show herniated mesenteric fat through two separate diaphragmatic defects (B. Those with blunt cardiac injury (contusion) are typically fol- Fig. periaortic hematoma. Most affected patients do not reach the hospital alive. a remnant of the ductus arteriosus that can normally be found in this location . A traumatic hemopericardium or pneumopericardium can cause cardiac tamponade requiring urgent decompression. Cardiac injury can occur from blunt and penetrating injury [4. luminal clots. accounting for the instability of this pseudoaneurysm and a high mortality (80% – 85%). abrupt caliber changes. D ). and active contrast extravasation) should be sought [5. intimal flaps.imaging pediatric chest trauma 277 the proximal descending aorta. black arrow ) and under left hemidiaphragm (white arrowhead . occlusion of major branch vessels. The mechanism of TAI is believed to be the ligamentum arteriosum tethering the aorta at the moment of injury. with the resulting shearing forces leading to a tear in the intima and media . with penetrating trauma more common. (A ) Frontal CT scanogram shows abnormal contour of the left hemidiaphragm and air in the soft tissues of the lower chest wall (arrow ). 14. Injuries to the myocardium and valve apparatus are usually investigated with echocardiography [4. and in-hospital mortality 31% to 44% is within the first hours of admission . Because of this early mortality of typical TAI. Children with penetrating cardiac injury or hemodynamic instability generally require immediate surgical exploration. Additional signs for atypical TAI (eg. Note also air in the chest wall (C .
as demonstrated on the upper slices of an abdominal CT scan obtained for blunt abdominal trauma [2. viscera sign describes the close contact of the herniated stomach or liver with the posterior chest wall. and the oft-associated traumatic abnormalities in the lung bases.7. or viscera (Fig. abdomen. because of the complex shape of the thin diaphragmatic muscle. into the hemithorax is a diagnostic finding that is often associated with contralateral shift of the heart and mediastinum. rarely require specific intervention such as chest tube placement . difficult positioning. CT has been shown to be more sensitive for the demonstration of rib fractures. Diaphragmatic rupture may also result from serious blunt abdominal injury in children . and multidetector-row CT seems to fulfill those criteria.7. Herniation of aerated abdominal viscera.36]. most frequently the stomach. It is important to realize that development of signs of pulmonary edema on follow-up chest radiographs is caused more commonly by fluid overload from aggressive trauma resuscitation than by traumatic myocardial or valvular dysfunction. As discussed previously. The dependentThe arrival of an injured child in the trauma room is an upsetting event for all involved. chest. with no diaphragmatic leaflet holding it up against gravity and a lack of normal interposition of aerated posterior lung tissue [4.21. several authors have advocated the liberal use of such a total-body trauma CT protocol [35. For this reason. and pelvis to be performed in less than 1 minute. trauma is a frequent reason for referral . In the adult trauma literature. It is only natural that caregivers are inclined to use the most sensitive and fastest technology available to diagnose all injuries within the shortest possible time frame. Herniation of abdominal viscera may not occur until the patient is no longer receiving positive-pressure ventilation. views affected by overlying material or stabilization apparatus. because this modality is not prone to the technical limitations (eg. There are three arguments against the routine use of total-body CT in pediatric trauma imaging. with liver tissue compressed by the margins of the diaphragmatic defect.12. stating that it is cost effective in all unconscious patients . Because the nonsurgical management of even severe solid abdominal injury has increased in recent years.32]. The rim sign indicates a contour deformity of the partially herniated liver. without the need for repositioning the critically injured patient.37].19]. parenchymal organs. which may enlarge following the institution of positive-pressure ventilation . Clinically and radiographically unexpected findings in the lower thorax. The exception is a radiographically occult pneumothorax. the horizontal in-plane orientation of the diaphragmatic dome.33].278 westra & wallace lowed up by EKG and echocardiography for development of arrhythmias and cardiac dysfunction. Multidetector-row CT is extremely rapid. but most often it is clinically silent [4. The hourglass (or collar) sign indicates the constriction of partially herniated viscera by the edges of a small diaphragmatic defect. Diagnostic algorithms Diaphragm Traumatic rupture of the diaphragm occurs more commonly on the left than on the right because of the protective effect of the liver. 14). recent reports in the surgical literature have pointed out that findings of chest CT performed for minor trauma rarely influence clinical management [11. and there is more reliance on imaging diagnosis.5. Diagnosis of diaphragmatic rupture without visceral herniation remains difficult. First. Although these arguments can be used to justify the routine use of CT in pediatric trauma patients as well. pulmonary contusion and laceration. and poor exposure parameters) that can affect conventional radiography. allowing a complete contiguous scan of head. neck. There is generally no need for repeat imaging. and diaphragmatic rupture than plain radiography of the chest . pneumothorax. This herniation may have an acute clinical presentation because of strangulation. which may be confirmed with administration of water-soluble contrast . even with thin-section CT. In most hospitals in the United States.5. A number of diagnostic criteria have been proposed using thin-slice CT with multiplanar reformations. It is more frequently associated with penetrating injury to the upper abdomen and lower chest than with blunt chest trauma . Discontinuity of a hemidiaphragm may allow herniation of intraabdominal mesenteric fat. diaphragmatic ruptures and hernias are often unrecognized on chest radiography because of associated contusion or atelectasis in the lung bases. An anomalous position of a nasogastric tube tip above the left hemidiaphragm indicates herniation of the stomach. the performance of a chest CT is probably warranted only in children whose chest injury is severe enough to require mechanical ventilation. hemothorax. Initially. there is the important issue of radiation dose in the pediatric age group . it has become even more imperative not to overlook this important lesion on CT .
however. The specific indications for chest CT in blunt trauma should be guided by the findings of the initial clinical examination and chest radiograph. a CT angiogram may be required to rule out a traumatic aortic injury in a patient with a borderline abnormal mediastinum on the chest radiograph.44]. A spinal fracture or fractures of the upper ribs. because of the potential catastrophic consequence of not diagnosing TAI in a timely manner. Given these controversies.48]. The CT should include coronal and sagittal reformatted images. who are more radiosensitive and have a longer potential lifespan in which to express radiation-induced tumors . When large segments of these scans are not clinically indicated in the first place. Clini- cians may perform costly and sometimes invasive additional imaging tests and treatments that can lead to iatrogenic complications and unnecessary expense . This decision should be influenced by the severity of pelvic and major extremity fractures. Cognitive impairment from low-dose radiation exposure in infancy has also recently been suggested . adds substantially to the medical radiation burden and consequently to the cancer induction risk estimates for the entire exposed population . shoulder girdle. and neurologic deficit on clinical examination.47]. and respiratory failure. CT becomes dose effective only if the information from a particular CT study is expected. and lumbar spine [43. This increased use of imaging. but the decision as to whether to carry the scan down through the rest of the body should be a clinical one. Arguably. a priori. this pseudodisease would have simply remained unnoticed. and there is a critical need for developing clinical appropriateness criteria for the application of CT in pediatric trauma patients [47. Proponents of the use of routine continuous total-body CT have pointed out that some radiation dose can be saved by eliminating overlapping segments from separate acquisitions  and by substituting multiplanar reformatted CT images for conventional radiographs of the cervical. because it is perceived as being the most accurate test for trauma imaging. AP radiograph of the pelvis and chest). This consideration is especially important in children. For example. presence of multiple other significant injuries). In the presence of an ab- . the authors believe that the initial imaging evaluation of pediatric trauma should consist of the conventional trauma series (lateral in-collar radiograph of the cervical spine. the performance of a total-body multidetector-row CT may be considered. in the correct clinical setting (high-velocity deceleration trauma mechanism. a high index of suspicion should be maintained for this condition. because the risk of occult internal injury is high in these patients.49. Second. Unconscious patients and those with suspicion for unstable fractures on the lateral spine radiograph will generally undergo CT of the head and cervical spine. Third. a CT is indicated to look for bronchial or vascular injury. such modest savings in radiation dose are more than offset by the fact that CT doses are an order of magnitude higher than corresponding conventional examinations . Because the radiation dose of one chest CT can equal that of approximately 250 chest radiographs. in conjunction with a careful and rapid triage by an experienced clinician and taking the mechanism and force of injury into account . all patients with penetrating injury should eventually undergo a CT focused on the area of impact. a CT of the relevant area should be performed. Although traumatic aortic injury in children remains rare despite the increased incidence of motor vehicle accidents. Before CT was available.imaging pediatric chest trauma 279 for CT imaging. Such reasoning can be used to develop appropriateness criteria for the application of CT in other clinical settings as well. to have a value that is substantially higher that of the corresponding chest radiograph. hemodynamic instability. without adverse effect on patient outcome. The indication for the placement of chest tubes is most often clinical or is visible on chest radiographs. as demonstrated on the initial radiographic trauma series. If a spinal fracture is clinically suspected or demonstrated on the initial radiographic survey. The fact that many of the injuries demonstrated do not impact patient management or treatment further underscores the need to perform these outcome and cost-effectiveness studies [12. there are considerations of cost effectiveness in the use of expensive imaging resources [46. but if there is persistent hemorrhagic output from these tubes or progressive pneumomediastinum. and sternum will often necessitate a contrastenhanced CT to look for vascular injury. This approach will determine the need for additional imaging with crosssectional techniques. thoracic. such as ultrasound and spiral or multidetector-row CT. there is the risk of the possible demonstration of pseudodisease and clinically unimportant findings by overinterpretation of CT findings. which has only occurred in the past decade.37.50]. Because the simultaneous occurrence of several of these injuries constitutes major multitrauma and suggests a highenergy impact. There is concern that the current medico-legal climate favors defensive medical practices that may lead to overuse of CT.
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