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.
Similar content being viewed by others
References
Bliss D, Silen M (2002) Pediatric thoracic trauma. Crit Care Med 30 [Suppl]:S409–S415
Cooper A, Barlow B, DiScala C et al (1994) Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 29:33–38
Sartorelli KH, Vane DW (2004) The diagnosis and management of children with blunt injury of the chest. Semin Pediatr Surg 13:98–105
Tovar JA (2008) The lung and pediatric trauma. Semin Pediatr Surg 17:53–59
Nakayama DK, Ramenofsky ML, Rowe MI (1989) Chest injuries in childhood. Ann Surg 210:770–775
Brenner DJ, Hall EJ (2007) Computed tomography – an increasing source of radiation exposure. N Engl J Med 357:2277–2284
Goske MJ, Applegate KE, Boylan J et al (2008) The ‘Image Gently’ campaign: increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol 38:265–269
Roux P, Fisher RM (1992) Chest injuries in children: an analysis of 100 cases of blunt chest trauma from motor vehicle accidents. J Pediatr Surg 27:551–555
Garcia VF, Gotschall CS, Eichelberger MR et al (1990) Rib fractures in children: a marker of severe trauma. J Trauma 30:695–700
Westra SJ, Wallace EC (2005) Imaging evaluation of pediatric chest trauma. Radiol Clin North Am 43:267–281
Donnelly LF, Frush DP (1999) Abnormalities of the chest wall in pediatric patients. AJR 173:1595–1601
Livingston DH, Shogan B, John P et al (2008) CT diagnosis of rib fractures and the prediction of acute respiratory failure. J Trauma 64:905–911
Hall A, Johnson K (2002) The imaging of paediatric thoracic trauma. Paediatr Rev 3:241–247
el-Khoury GY, Whitten CG (1993) Trauma to the upper thoracic spine: anatomy, biomechanics, and unique imaging features. AJR 160:95–102
Soldati G, Testa A, Sher S et al (2008) Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest 133:204–211
Wolfman NT, Myers WS, Glauser SJ et al (1998) Validity of CT classification on management of occult pneumothorax: a prospective study. AJR 171:1317–1320
Holmes JF, Brant WE, Bogren HG et al (2001) Prevalence and importance of pneumothoraces visualized on abdominal computed tomographic scan in children with blunt trauma. J Trauma 50:516–520
Ball CG, Hameed SM, Evans D et al (2003) Canadian trauma trials collaborative. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg 46:373–379
de Moya MA, Seaver C, Spaniolas K et al (2007) Occult pneumothorax in trauma patients: development of an objective scoring system. J Trauma 63:13–17
Chan O, Hiorns M (1996) Chest trauma. Eur J Radiol 23:23–34
McEwan K, Thompson P (2007) Ultrasound to detect haemothorax after chest injury. Emerg Med J 24:581–582
Taylor GA, Kaufman RA, Sivit CJ (1994) Active hemorrhage in children after thoracoabdominal trauma: clinical and CT features. AJR 162:401–404
Balci AE, Kazez A, Eren S et al (2004) Blunt thoracic trauma in children: review of 137 cases. Eur J Cardiothorac Surg 26:387–392
Schild HH, Strunk H, Weber W et al (1989) Pulmonary contusion: CT vs plain radiograms. J Comput Assist Tomogr 13:417–420
Donnelly LF, Klosterman LA (1997) Subpleural sparing: a CT finding of lung contusion in children. Radiology 204:385–387
Kwon A, Sorrells DL Jr, Kurkchubasche AG et al (2006) Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity. J Pediatr Surg 41:78–82
Soldati G, Testa A, Silva FR et al (2006) Chest ultrasonography in lung contusion. Chest 130:533–538
Peclet MH, Newman KD, Eichelberger MR et al (1990) Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg 25:961–965
Tsitouridis I, Tsinoglou K, Tsandiridis C et al (2007) Traumatic pulmonary pseudocysts: CT findings. J Thorac Imaging 22:247–251
Mudd KL, Hunt A, Matherly RC et al (2000) Analysis of pulmonary fat embolism in blunt force fatalities. J Trauma 48:711–715
Wintermark M, Schnyder P (2001) The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest 120:543–547
Gouda HS, Shashidhar, Mestri C (2008) Mediastinal emphysema due to an isolated facial trauma: a case report. Med Sci Law 48:178–180
Feldman MG, Lustberg H (1999) Pneumomediastinum: retroperitoneal pathway. Conn Med 63:579–582
Schulman A, Fataar S, Van der Spuy JW et al (1982) Air in unusual places: some causes and ramifications of pneumomediastinum. Clin Radiol 33:301–306
Nugteren P, Paul MA, Plötz FB (2007) Rupture of the right main bronchus: a case of a 4-year-old girl. Eur J Emerg Med 14:97–99
Harvey-Smith W, Bush W, Northrop C (1980) Traumatic bronchial rupture. AJR 134:1189–1193
Mahboubi S, O’Hara AE (1981) Bronchial rupture in children following blunt chest trauma. Report of five cases with emphasis on radiologic findings. Pediatr Radiol 10:133–138
Ozdulger A, Cetin G, Erkmen Gulhan S et al (2003) A review of 24 patients with bronchial ruptures: is delay in diagnosis more common in children? Eur J Cardiothoracic Surg 23:379–383
Scaglione M, Romano S, Pinto A et al (2006) Acute tracheobronchial injuries: impact of imaging on diagnosis and management implications. Eur J Radiol 59:336–343
Le Guen M, Beigelman C, Bouhemad B et al (2007) Chest computed tomography with multiplanar reformatted images for diagnosing traumatic bronchial rupture: a case report. Crit Care 11:R94
Sinclair DS (2002) Traumatic aortic injury: an imaging review. Emerg Radiol 9:13–20
Heckman SR, Trooskin SZ, Burd RS (2005) Risk factors for blunt thoracic aortic injury in children. J Pediatr Surg 40:98–102
Lowe LH, Bulas DI, Eichelberger MD et al (1998) Traumatic aortic injuries in children: radiologic evaluation. AJR 170:39–42
Mirvis SE, Bidwell JK, Buddemeyer EU et al (1987) Value of chest radiography in excluding traumatic aortic rupture. Radiology 163:487–493
Ng CJ, Chen JC, Wang LJ et al (2006) Diagnostic value of the helical CT scan for traumatic aortic injury: correlation with mortality and early rupture. J Emerg Med 30:277–282
Anderson SA, Day M, Chen MK et al (2008) Traumatic aortic injuries in the pediatric population. J Pediatr Surg 43:1077–1081
Demetriades D, Velmahos GC, Scalea TM et al (2008) Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 64:1415–1418
Lomoschitz FM, Eisenhuber E, Linnau KF et al (2003) Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms. Eur J Radiol 48:61–70
John V, Mathai J, Chacko J et al (2006) Tracheoesophageal fistula in a child after blunt chest trauma. J Pediatr Surg 41:E27–E29
Sakamoto Y, Seki Y, Tanaka N et al (2000) Tracheoesophageal fistula after blunt chest trauma: successful diagnosis by computed tomography. Thorac Cardiovasc Surg 48:102–103
Markarian MK, MacIntyre DA, Cousins BJ et al (2008) Adolescent pneumopericardium and pneumomediastinum after motor vehicle crash and ejection. Am J Emerg Med 26:515.e1–515.e2
Dowd MD, Krug S (1996) Pediatric blunt cardiac injury: epidemiology, clinical features, and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. J Trauma 40:61–67
Ozay B, Ozer N, Ketenci B et al (2008) Unsuspected location of a ventricular septal defect after blunt chest trauma. Thorac Cardiovasc Surg 56:110–111
Sahebjam M, Marzban M, Soleimani A et al (2007) A rare cause of chronic mitral regurgitation: perivalvular ventriculoatrial fistulous communication from remote blunt chest trauma. J Am Soc Echocardiogr 20:1416.e3–1416.e5
Asai Y, Kurimoto Y (2007) Impending rupture of a blunt trauma-induced left ventricular aneurysm: report of a case. Surg Today 37:971–973
Eren S, Kantarci M, Okur A (2006) Imaging of diaphragmatic rupture after trauma. Clin Radiol 61:467–477
Ramos CT, Koplewitz BZ, Babyn PS et al (2000) What have we learned about traumatic diaphragmatic hernias in children. J Pediatr Surg 35:601–604
Soundappan SV, Holland AJ, Cass DT et al (2005) Blunt traumatic diaphragmatic injuries in children. Injury 36:51–54
Iochum S, Ludig T, Walter F et al (2002) Imaging of diaphragmatic injury: a diagnostic challenge. Radiographics 22(Spec No):S103–S116
Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR 184:24–30
Alper B, Vargun R, Kologlu MB et al (2007) Late presentation of a traumatic rupture of the diaphragm with gastric volvulus in a child: report of a case. Surg Today 37:874–877
Rocco M, Carbone I, Morelli A et al (2008) Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma. Acta Anaesthesiol Scand 52:776–784
Testerman GM (2006) Surgeon-performed ultrasound in the diagnosis and management of pericardial tamponade in a 20-month-old blunt injured toddler. Tenn Med 99:37–38
Jin W, Yang DM, Kim HC et al (2006) Diagnostic values of sonography for assessment of sternal fractures compared with conventional radiography and bone scans. J Ultrasound Med 25:1263–1268
Brink M, Deunk J, Dekker HM (2008) Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management. AJR 190:1591–1598
Donnelly LF (2005) Reducing radiation dose associated with pediatric CT by decreasing unnecessary examinations. AJR 184:655–657
Brenner D, Elliston C, Hall E et al (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR 176:289–296
Mazrani W, McHugh K, Marsden PJ (2007) The radiation burden of radiological investigations. Arch Dis Child 92:1127–1131
Paterson A, Frush DP (2007) Dose reduction in paediatric MDCT: general principles. Clin Radiol 62:507–517
Hall EJ, Brenner DJ (2008) Cancer risks from diagnostic radiology. Br J Radiol 81:362–378
Hall EJ (2002) Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 32:700–706
Holmes JF, Sokolove PE, Brant WE et al (2002) A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 39:492–499
Linton OW, Mettler FA Jr (2003) National Council on Radiation Protection and Measurements. National conference on dose reduction in CT, with an emphasis on pediatric patients. AJR 181:321–329
Li J, Udayasankar UK, Toth TL et al (2007) Automatic patient centering for MDCT: effect on radiation dose. AJR 188:547–552
Kalender WA, Buchenau S, Deak P et al (2008) Technical approaches to the optimisation of CT. Phys Med 24:71–79
Huda W, Vance A (2007) Patient radiation doses from adult and pediatric CT. AJR 188:540–546
Siegel MJ, Schmidt B, Bradley D et al (2004) Radiation dose and image quality in pediatric CT: effect of technical factors and phantom size and shape. Radiology 233:515–522
Smith AB, Dillon WP, Lau BC et al (2008) Radiation dose reduction strategy for CT protocols: successful implementation in neuroradiology section. Radiology 247:499–506
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Moore, M.A., Wallace, E.C. & Westra, S.J. The imaging of paediatric thoracic trauma. Pediatr Radiol 39, 485–496 (2009). https://doi.org/10.1007/s00247-008-1093-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00247-008-1093-5