Operative treatment is indicated in cases of persistent bleeding, hemodynamic instability, or to rule out a missed injury.
Dr. Grabowski pointed out that there is little value in routine follow-up imaging studies after splenic or hepatic injury. The American Pediatric Surgical Association guidelines recommend a return to normal activities after a period of 2 weeks plus the grade of injury. "Normal activity is considered returning to school and walking," she said. "It’s not return to sports competition like football or wrestling. We usually say if your spleen gets injured during the football season, you can return to play the following season."
Bowel injuries comprise just 15% of intra-abdominal injuries in children, "but there is a high mortality, about 25%, and they’re easily missed on initial exam," Dr. Grabowski said. Clinical examination remains the most important diagnostic tool in the awake patient because only 60% of radiographic studies will be diagnostic. "It’s a difficult diagnosis to make, and delays occur in about 10% of cases," she said. "But many good studies have shown that children who have a delayed diagnosis of bowel injury did not have a worse outcome."
Seat belt injures also are common because most children are too large for car seats and too small for an adult seat belt system. "So they either don’t wear the cross-chest harness or they wear it inappropriately," Dr. Grabowski said. "Children also have a higher center of gravity, an immaturity and lack of structural integrity of their bony pelvis, and in most cases they have a relative paucity of abdominal musculature. Because they’re wearing their seat belt wrong they have a tendency to get injured by their seat belt more often than adults do."
An estimated 50%-70% of seat belt injuries are associated with a chance fracture, or a rupture of the posterior spinal ligament, or wedge, most commonly at L1 and L3. Those particular injuries "are very often associated with a bowel injury, so there’s a high index of suspicion in those children," she said. Indications for exploration in children who present with seat belt injuries include hemodynamic instability, pneumoperitoneum, peritonitis, bladder rupture, abdominal tenderness with free fluid in pelvis on CT without solid organ injury, if they worsen on exam, if they spike a fever, or if their labs become abnormal.
Dr. Grabowski advises clinicians to think nonaccidental trauma if children present with no history or explanation for injury, if the history is incompatible with the type or degree of injury, if a sibling is blamed for the injury, if caregivers give conflicting histories when interviewed separately, or if the history is not credible. "Health care providers are mandated reporters of nonaccidental trauma," she said, noting than an estimated 1 million children are victims of abuse each year.
Dr. Grabowski said that she had no relevant financial conflicts to make.