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Clinical Summary

Intra-abdominal and intrathoracic injuries are identified in a small but important fraction of abused children. These injuries can be deadly and can significantly affect the plausibility of an offered history for other injuries. Clinical signs of abdominal injury (tenderness, bruising, distention, altered bowel sounds) are relatively specific but relatively insensitive. Hepatic transaminases (AST and ALT) can identify abdominal injuries that are missed by clinical examination alone and should be obtained in children < 5 years old with concern for physical abuse and a significant injury. When AST or ALT are > 80 IU/L, abdominal CT with intravenous (IV) contrast should be obtained to identify intra-abdominal injury.

Significant intra-abdominal injuries are uncommonly the result of short falls or stairway falls, although relatively low-energy injuries with a direct blow to the abdomen (eg, a fall onto handlebars) can produce significant injuries.

Management and Disposition

Most solid organ injuries in well-appearing children are self-limited, but hollow viscus injuries, pancreatic injuries, and vascular injuries have high likelihood of deterioration and require early surgical consultation. Children with identified intra-abdominal or intrathoracic injuries require admission for observation and surgical consultation. The identification of abusive intra-abdominal or intrathoracic injuries should prompt screening for other abusive injuries with a careful physical examination, skeletal survey (for children < 24 months old), and neuroimaging (for children < 6 months old or with signs of brain injury).

FIGURE 15.76

Abdominal Bruises. Abdominal bruising is unlikely in accidental injury and frequently indicates intra-abdominal injury. (Photo contributor: Kathi L. Makoroff, MD.)

FIGURE 15.77

Positive Focused Assessment with Sonography for Trauma (FAST) Examination. This anechoic (dark) fluid in Morrison pouch represented blood in this patient. As with nonabusive trauma, ultrasound is a rapid, noninvasive way to screen for abdominal injury in an unstable patient but is not sufficiently sensitive to detect smaller abdominal injuries that may, nevertheless, have important forensic significance. (Photo contributor: Jason W. Fischer, MD, MSc.)

FIGURE 15.78

Hollow Viscus Perforation. This lateral chest x-ray demonstrates free air anteriorly, inferior to the diaphragm, suggesting hollow viscus perforation, an injury that, like pancreatic injuries, is overrepresented in abused children. (Photo contributor: Cincinnati Children’s Hospital Medical Center.)

FIGURE 15.79

Splenic Laceration. A severe laceration of the spleen is seen. Note the large separation of the splenic parenchyma with fluid density (blood) visible between the sections of the spleen (white arrows) and free fluid within the peritoneum (large white arrow). In young children, motor vehicle collisions and abuse account for the large majority of such injuries. (Photo contributor: Marguerite Caré, MD.)

FIGURE 15.80

Splenic Laceration....

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