Can falls on stairs result in small intestine perforations?

Isolated duodenal perforation in children: Importance of high index of suspicion following blunt trauma abdomen

Introduction

Isolated duodenal perforation (IDP) is rare and only isolated cases are reported in the literature. Due to its rarity and subtle presentation, the diagnosis of IDP is often delayed. Delay in the diagnosis and surgical intervention result in increased morbidity and mortality. The aim of this article is to highlight the importance of a high index of suspicion of IDP following blunt abdominal trauma and safety of primary repair without diversion in such cases.

Material and methods

Children with isolated duodenal injuries following blunt abdominal trauma were included; mode of trauma, clinical presentation, diagnosis, operative intervention and outcome were studied.

Results

Nine patients with isolated duodenal perforations were identified and operated on. Most had minimal clinical findings on arrival and were haemodynamically stable. Abdominal radiography and ultrasonography were unremarkable. However, pain remained persistent and worsening of vomiting was seen over time. Contrast-enhanced computed tomography (CECT) of the abdomen with oral and intravenous contrast was done to identify the injuries. Primary repair of perforation was performed in all cases. The most common cause was road traffic accident. There were three Grade 2 injuries, five Grade 3 and one Grade 4 injuries. Eight patients healed well with uneventful recovery – one patient died from sepsis after presenting 24 h after injury with frank peritonitis.

Conclusion

Isolated duodenal perforation presents without specific signs and symptoms and a high index of suspicion is necessary for early diagnosis. Contrast-enhanced computed tomography of the abdomen with oral contrast should be ordered early if symptoms persist or worsened over time.

Evaluation of the abdomen in the setting of suspected child abuse

Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.

Ethical Testimony in Cases of Suspected Child Maltreatment: The Ray E. Helfer Society Guidelines

New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.

Pediatric abdominal injury patterns caused by "falls": A comparison between nonaccidental and accidental trauma

BACKGROUND/PURPOSE

Falling from a low height is the most common history given by caregivers of pediatric nonaccidental trauma (NAT) victims evaluated for blunt abdominal trauma (BAT). The purpose of this study is to compare the patterns of injuries seen in children with BAT who are victims of NAT with those seen after a fall-related incident.

METHODS

Trauma database query from regional pediatric trauma centers identified patients were who were evaluated for BAT resulting from either NAT or a fall. Study groups included patients younger than five years who were (1) victims or NAT, or (2) fall casualties.

RESULTS

Sixty-five NATs and 115 fall casualties were identified. NAT victims had higher ISS, had more severe head injuries according to AIS scores, had more hollow viscus injuries, and had more pancreatic injuries. Fall casualties were more likely to have solid organ injuries.

CONCLUSIONS

When evaluating children with a history of blunt abdominal trauma caused by a fall, suspicion for NAT is warranted if the child is younger than five years, has a hollow viscus, pancreatic, and/or severe head injury and has a high ISS. Likewise, isolated splenic or renal injury allays suspicion for NAT.

Pediatric nonaccidental abdominal trauma: what the radiologist should know

Abdominal injury in nonaccidental trauma (NAT) is an increasingly recognized cause of hospitalization in abused children. Abdominal injuries in NAT are often severe and have high rates of surgical intervention. Certain imaging findings in the pediatric abdomen, notably bowel perforation and pancreatic injury, should alert the radiologist to possible abuse and incite close interrogation concerning the reported mechanism of injury. Close inspection of the imaging study is warranted to detect additional injury sites because these injuries rarely occur in isolation. When abdominal injury is suspected in known or speculated NAT, computed tomography (CT) of the abdomen and pelvis with intravenous contrast material is recommended for diagnostic and forensic evaluation. Although the rate of bowel injury is disproportionately high in NAT, solid organs, including the liver, pancreas, and spleen, are most often injured. Adrenal and renal trauma is less frequent in NAT and is generally seen with multiple other injuries. Hypoperfusion complex is a constellation of abdominal CT findings that indicates current or impending decompensated shock and is most often due to severe neurologic impairment in NAT. Although abdominal injuries in NAT are relatively uncommon, knowledge of injury patterns and their imaging appearances is important for patient care and protection.

An isolated duodenal perforation in pediatric blunt abdominal trauma: a rare but distinct possibility

Isolated duodenal perforation (IDP) in pediatric trauma is rarely reported. Since most of the children with blunt trauma are managed expectantly, timely diagnosis is imperative to avoid morbidity and mortality. We report a case of IDP and emphasize on certain specific clinical features indicating possibility of duodenal injury. We also stress upon the role of early contrast-enhanced computerized tomography (CECT) in such cases.

A systematic review of abusive visceral injuries in childhood--their range and recognition

OBJECTIVES

To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children.

METHODS

We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome.

RESULTS

Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated.

CONCLUSIONS

Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.

Utility of hepatic transaminases in children with concern for abuse

OBJECTIVE

Routine testing of hepatic transaminases, amylase, and lipase has been recommended for all children evaluated for physical abuse, but rates of screening are widely variable, even among abuse specialists, and data for amylase and lipase testing are lacking. A previous study of screening in centers that endorsed routine transaminase screening suggested that using a transaminase threshold of 80 IU/L could improve injury detection. Our objectives were to prospectively validate the test characteristics of the 80-IU/L threshold and to determine the utility of amylase and lipase to detect occult abdominal injury.

METHODS

This was a retrospective secondary analysis of the Examining Siblings To Recognize Abuse research network, a multicenter study in children younger than 10 years old who underwent subspecialty evaluation for physical abuse. We determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing. Screening studies were compared by using basic test characteristics (sensitivity, specificity) and the area under the receiver operating characteristic curve.

RESULTS

Abdominal injuries were identified in 82 of 2890 subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for amylase and lipase were 0.67 and 0.72, respectively.

CONCLUSIONS

Children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury.

Do resuscitation-related injuries kill infants and children?

Occasionally, individuals accused of inflicting fatal injuries on infants and young children will claim some variant of the "CPR defense," that is, they attribute the cause of injuries found at autopsy to their "untrained" resuscitative efforts. A 10-year (1994-2003) historical fixed cohort study of all pediatric forensic autopsies at the Miami-Dade County Medical Examiner Department was undertaken. To be eligible for inclusion in the study, children had to have died of atraumatic causes, with or without resuscitative efforts (N(atraumatic) = 546). Of these, 382 had a history of cardiopulmonary resuscitation (CPR; average age of 4.17 years); 248 had CPR provided by trained individuals only; 133 had CPR provided by both trained and untrained individuals; 1 had CPR provided by untrained individuals only. There was no overlap between these 3 distinct groups. Twenty-two findings potentially attributable to CPR were identified in 19:15 cases of orofacial injuries compatible with attempted endotracheal intubation; 4 cases with focal pulmonary parenchymal hemorrhage; 1 case with prominent anterior mediastinal emphysema; and 2 cases with anterior chest abrasions. There were no significant hollow or solid thoracoabdominal organ injuries. There were no rib fractures. The estimated relative risk of injury subsequent to resuscitation was not statistically different between the subset of decedents whose resuscitative attempts were made by trained individuals only, and the subset who received CPR from both trained and untrained individuals. In the single case of CPR application by an untrained individual only, no injuries resulted. The remaining 164 children dying from nontraumatic causes and who did not undergo resuscitative efforts served as a control group; no injuries were identified. This study indicates that in the pediatric population, injuries secondary to resuscitative efforts are infrequent or rare, pathophysiologically inconsequential, and predominantly orofacial in location. In our population, CPR did not result in any rib fractures or significant visceral injuries. Participation of nonmedical or untrained individuals in resuscitation did not increase the likelihood of injury.

Utility of hepatic transaminases to recognize abuse in children

OBJECTIVE

Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse.

PATIENTS AND METHODS

This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken.

RESULTS

Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity.

CONCLUSIONS

In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.

Staircase falls: high-risk groups and injury characteristics in 464 patients

INTRODUCTION

Few data are available about the epidemiology and injury characteristics in staircase falls. The available literature mainly concerns children and autopsy studies.

OBJECTIVE

To describe the epidemiology and injury characteristics of staircase falls, and to identify high-risk groups for these falls.

METHODS

All patients who reported to an academic Accident & Emergency (A&E) department in 2005 after a staircase fall were selected in the Dutch Injury Surveillance System These data were linked to the hospital Trauma Registry database.

RESULTS

Four hundred and sixty-four patients (42% male, p=0.001), with a median age of 35 years were included. Children under five suffered significantly more head injuries. Male patients showed significantly more thoracic injuries than female patients. Spinal column fractures were only seen in patients over 25 years of age. Older patients tended to accumulate more rib fractures and lower extremity fractures and were admitted more frequently than the younger patients. Sixty-one patients (13%) required admission. Two patients, both with severe traumatic brain injury (TBI), died. National data on staircase falls were comparable with our hospital data. However, in comparison to the national population data, senior citizens in this study had an incidence that was markedly higher than in the younger patients.

CONCLUSION

Injuries due to staircase falls occur in all age groups, however, children under five years are relatively over-represented with higher rates of head injury. Senior citizens showed a markedly higher incidence than younger patients. Most injuries occur to the distal extremities and are relatively mild.

Small bowel perforation and fatal peritonitis following a fall in a 21-month-old child

The authors report a case of fatal peritonitis due to small bowel perforation in a 21-month-old female child. Necropsy excluded natural disease and a thorough Coronial investigation concluded that an accidental fall onto a "doorstop" caused the bowel injury. The investigative findings are presented; the discussion address issues of diagnosis and causation/mechanism of injury.

Physical abuse and neglect of children

Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor's ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.

Isolated jejunal perforation after blunt thoracoabdominal trauma

A case report of isolated jejunal perforation secondary to a relatively unique mechanism of blunt thoracoabdominal trauma is presented. A thorough and concise review of the multimodal approach that may be necessary to diagnose such a rare clinical problem is discussed.

Abdominal injury due to child abuse

Diagnosis of abuse in children with internal abdominal injury is difficult because of limited published work. We aimed to ascertain the incidence of abdominal injury due to abuse in children age 0-14 years. 20 children (identified via the British Paediatric Surveillance Unit) had abdominal injuries due to abuse and 164 (identified via the Trauma Audit and Research Network) had injuries to the abdomen due to accident (112 by road-traffic accidents, 52 by falls). 16 abused children were younger than 5 years. Incidence of abdominal injury due to abuse was 2.33 cases per million children per year (95% CI 1.43-3.78) in children younger than 5 years. Six abused children died. 11 abused children had an injury to the gut (ten small bowel) compared with five (all age >5 years) who were injured by a fall (relative risk 5.72 [95% CI 2.27-14.4]; p=0.0002). We have shown that small-bowel injuries can arise accidentally as a result of falls and road-traffic accidents but they are significantly more common in abused children. Therefore, injuries to the small bowel in young children need special consideration, particularly if a minor fall is the explanation.

Femur fractures resulting from stair falls among children: an injury plausibility model

BACKGROUND

Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP).

METHODS

Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries.

RESULTS

Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types.

CONCLUSIONS

This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall-related femur fractures and identifies key characteristics to facilitate decision-making.

Accidental or inflicted?

The visible evidence of child physical abuse most often is minimal or nonexistent, and the children at greatest risk of becoming victims are those too young to verbalize the history. As pediatric clinicians, we must be able to recognize potential sequelae of abuse and the high-risk situations that lead to physical abuse; we also must acknowledge that victims of child physical abuse often have injuries at multiple locations and in multiple organ systems. As a routine part of pediatric practice, healthcare providers, through anticipatory guidance, try to maximize the child's safety in the home environment. With this goal in mind, healthcare providers must consider the possibility of physical abuse when faced with a child with a traumatic injury. While it is important to identify these inflicted injuries, our ultimate goal is to prevent their occurrence in the first place.

Duodenal injuries in children: beware of child abuse

PURPOSE

It is frequently overlooked that child abuse may result in significant intraabdominal injury, particularly to the duodenum. The authors hypothesized that a significant number of duodenal injuries in young children would be the result of nonaccidental trauma.

METHODS

An 8-year (1995 through 2002) retrospective review of a pediatric level I trauma center database was performed after Institutional Review Board approval was obtained, and information regarding patients with duodenal injury was abstracted. Demographic variables, injury severity, length of stay, mortality rate, and mechanism of injury were examined. Statistical analysis was performed using descriptive statistics and Student's t test. Statistical significance was defined as P less than.05.

RESULTS

Over the 8-year study period, 8,968 patients were admitted, 2,179 (24%) were less than 3 years of age. Thirty children (0.3%) suffered injury to the duodenum, with 20 hematomas and 10 perforations. Patients were overwhelmingly boys (80%), with an average age of 7.6 +/- 4.4 years and Injury Severity Score (ISS) of 14 +/- 10. No patients died. Children were injured by a variety of mechanisms, including collisions involving motor vehicles (n = 9), bicycles (n = 4), and ATVs (n = 2). However, all children less than 4 years of age (n = 8) were victims of nonaccidental trauma, 2.8% of all child abuse admissions. Three of these children suffered perforations of the duodenum. Among the entire population, those children who suffered perforations had a significantly higher ISS (23.7 +/- 7.2 v 9.6 +/- 7.3; P <.0003) and longer length of stay (27.1 +/- 15.3 v 12.6 +/- 11.7; P <.007) than those with hematomas

CONCLUSIONS

Injury to the duodenum is unusual in the pediatric trauma patient but does result in significant injury severity and prolonged hospitalization. In the young child, one must maintain a high index of suspicion regarding the etiology of the injury, because a large percentage is potentially the result of child abuse.

From the archives of the AFIP. Child abuse: radiologic-pathologic correlation

In the United States, roughly one of every 100 children is subjected to some form of neglect or abuse; inflicted injury is responsible for approximately 1,200 deaths per year. Child physical abuse may manifest as virtually any injury pattern known to medicine. Some of the injuries observed in battered children are relatively unique to this population (especially when observed in infants) and therefore are highly suggestive of nonaccidental, or inflicted, injury. Worrisome injuries include rib fracture, metaphyseal fracture, interhemispheric extraaxial hemorrhage, shear-type brain injury, vertebral compression fracture, and small bowel hematoma and laceration. As noted, however, virtually any injury may be inflicted; therefore, careful consideration of the nature of the injury, the developmental capabilities of the child, and the given history are crucial to determine the likelihood that an injury was inflicted. The majority of these injuries are readily detectable at imaging, and radiologic examination forms the mainstay of evaluation of child physical abuse. Detection of metaphyseal fracture (regarded as the most specific radiographically detectable injury in abuse) depends on high-quality, small field-of-view radiographs. The injury manifests radiographically as a lucent area within the subphyseal metaphysis, extending completely or partially across the metaphysis, roughly perpendicular to the long axis of the bone. Acute rib fractures (which in infants are strongly correlated with abuse) appear as linear lucent areas. They may be difficult to discern when acute; thus, follow-up radiography increases detection of these fractures. For skull injuries, radiography is best for detecting fractures, but computed tomography and magnetic resonance imaging best depict intracranial injury.

Abdominal and pelvic trauma in children

Trauma is the leading cause of death and disability in children. More than 90% of pediatric trauma admissions are the result of a blunt mechanism. Although injury to the abdomen and pelvis account for only 10% of injuries sustained by victims of pediatric trauma, they can be potentially life threatening. Optimal evaluation of the injured child may require the use of multiple diagnostic modalities. The spleen is the most frequently injured intra-abdominal organ, followed by the liver, intestine, and pancreas. Fortunately, the majority of injuries to the spleen and liver can be treated nonoperatively. Conversely, injuries involving the intestine and pancreas often require operative intervention.

Pediatric trauma: postinjury care in the pediatric intensive care unit

Traumatic injuries occur in > 20 million children each year and are the leading source of death in children over the age of 1 yr. Mechanisms of injury and subsequent therapies for critically injured children are diverse. This review will focus on resources and management strategies for caring for the severely injured child in the pediatric intensive care unit.