Pediatric Radiology

, Volume 39, Issue 5, pp 485–496 | Cite as

The imaging of paediatric thoracic trauma

  • Michael A. Moore
  • E. Christine Wallace
  • Sjirk J. WestraEmail author


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.


Chest Trauma Multidetector CT Children 


  1. 1.
    Bliss D, Silen M (2002) Pediatric thoracic trauma. Crit Care Med 30 [Suppl]:S409–S415PubMedCrossRefGoogle Scholar
  2. 2.
    Cooper A, Barlow B, DiScala C et al (1994) Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 29:33–38PubMedCrossRefGoogle Scholar
  3. 3.
    Sartorelli KH, Vane DW (2004) The diagnosis and management of children with blunt injury of the chest. Semin Pediatr Surg 13:98–105PubMedCrossRefGoogle Scholar
  4. 4.
    Tovar JA (2008) The lung and pediatric trauma. Semin Pediatr Surg 17:53–59PubMedCrossRefGoogle Scholar
  5. 5.
    Nakayama DK, Ramenofsky ML, Rowe MI (1989) Chest injuries in childhood. Ann Surg 210:770–775PubMedCrossRefGoogle Scholar
  6. 6.
    Brenner DJ, Hall EJ (2007) Computed tomography – an increasing source of radiation exposure. N Engl J Med 357:2277–2284PubMedCrossRefGoogle Scholar
  7. 7.
    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 38:265–269PubMedCrossRefGoogle Scholar
  8. 8.
    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 27:551–555PubMedCrossRefGoogle Scholar
  9. 9.
    Garcia VF, Gotschall CS, Eichelberger MR et al (1990) Rib fractures in children: a marker of severe trauma. J Trauma 30:695–700PubMedCrossRefGoogle Scholar
  10. 10.
    Westra SJ, Wallace EC (2005) Imaging evaluation of pediatric chest trauma. Radiol Clin North Am 43:267–281PubMedCrossRefGoogle Scholar
  11. 11.
    Donnelly LF, Frush DP (1999) Abnormalities of the chest wall in pediatric patients. AJR 173:1595–1601PubMedGoogle Scholar
  12. 12.
    Livingston DH, Shogan B, John P et al (2008) CT diagnosis of rib fractures and the prediction of acute respiratory failure. J Trauma 64:905–911PubMedCrossRefGoogle Scholar
  13. 13.
    Hall A, Johnson K (2002) The imaging of paediatric thoracic trauma. Paediatr Rev 3:241–247CrossRefGoogle Scholar
  14. 14.
    el-Khoury GY, Whitten CG (1993) Trauma to the upper thoracic spine: anatomy, biomechanics, and unique imaging features. AJR 160:95–102PubMedGoogle Scholar
  15. 15.
    Soldati G, Testa A, Sher S et al (2008) Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest 133:204–211PubMedCrossRefGoogle Scholar
  16. 16.
    Wolfman NT, Myers WS, Glauser SJ et al (1998) Validity of CT classification on management of occult pneumothorax: a prospective study. AJR 171:1317–1320PubMedGoogle Scholar
  17. 17.
    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 50:516–520PubMedCrossRefGoogle Scholar
  18. 18.
    Ball CG, Hameed SM, Evans D et al (2003) Canadian trauma trials collaborative. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg 46:373–379PubMedGoogle Scholar
  19. 19.
    de Moya MA, Seaver C, Spaniolas K et al (2007) Occult pneumothorax in trauma patients: development of an objective scoring system. J Trauma 63:13–17PubMedCrossRefGoogle Scholar
  20. 20.
    Chan O, Hiorns M (1996) Chest trauma. Eur J Radiol 23:23–34PubMedCrossRefGoogle Scholar
  21. 21.
    McEwan K, Thompson P (2007) Ultrasound to detect haemothorax after chest injury. Emerg Med J 24:581–582PubMedCrossRefGoogle Scholar
  22. 22.
    Taylor GA, Kaufman RA, Sivit CJ (1994) Active hemorrhage in children after thoracoabdominal trauma: clinical and CT features. AJR 162:401–404PubMedGoogle Scholar
  23. 23.
    Balci AE, Kazez A, Eren S et al (2004) Blunt thoracic trauma in children: review of 137 cases. Eur J Cardiothorac Surg 26:387–392PubMedCrossRefGoogle Scholar
  24. 24.
    Schild HH, Strunk H, Weber W et al (1989) Pulmonary contusion: CT vs plain radiograms. J Comput Assist Tomogr 13:417–420PubMedCrossRefGoogle Scholar
  25. 25.
    Donnelly LF, Klosterman LA (1997) Subpleural sparing: a CT finding of lung contusion in children. Radiology 204:385–387PubMedGoogle Scholar
  26. 26.
    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 41:78–82PubMedCrossRefGoogle Scholar
  27. 27.
    Soldati G, Testa A, Silva FR et al (2006) Chest ultrasonography in lung contusion. Chest 130:533–538PubMedCrossRefGoogle Scholar
  28. 28.
    Peclet MH, Newman KD, Eichelberger MR et al (1990) Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg 25:961–965PubMedCrossRefGoogle Scholar
  29. 29.
    Tsitouridis I, Tsinoglou K, Tsandiridis C et al (2007) Traumatic pulmonary pseudocysts: CT findings. J Thorac Imaging 22:247–251PubMedCrossRefGoogle Scholar
  30. 30.
    Mudd KL, Hunt A, Matherly RC et al (2000) Analysis of pulmonary fat embolism in blunt force fatalities. J Trauma 48:711–715PubMedCrossRefGoogle Scholar
  31. 31.
    Wintermark M, Schnyder P (2001) The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest 120:543–547PubMedCrossRefGoogle Scholar
  32. 32.
    Gouda HS, Shashidhar, Mestri C (2008) Mediastinal emphysema due to an isolated facial trauma: a case report. Med Sci Law 48:178–180PubMedCrossRefGoogle Scholar
  33. 33.
    Feldman MG, Lustberg H (1999) Pneumomediastinum: retroperitoneal pathway. Conn Med 63:579–582PubMedGoogle Scholar
  34. 34.
    Schulman A, Fataar S, Van der Spuy JW et al (1982) Air in unusual places: some causes and ramifications of pneumomediastinum. Clin Radiol 33:301–306PubMedCrossRefGoogle Scholar
  35. 35.
    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 14:97–99PubMedCrossRefGoogle Scholar
  36. 36.
    Harvey-Smith W, Bush W, Northrop C (1980) Traumatic bronchial rupture. AJR 134:1189–1193PubMedGoogle Scholar
  37. 37.
    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 10:133–138PubMedCrossRefGoogle Scholar
  38. 38.
    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 23:379–383CrossRefGoogle Scholar
  39. 39.
    Scaglione M, Romano S, Pinto A et al (2006) Acute tracheobronchial injuries: impact of imaging on diagnosis and management implications. Eur J Radiol 59:336–343PubMedCrossRefGoogle Scholar
  40. 40.
    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:R94PubMedCrossRefGoogle Scholar
  41. 41.
    Sinclair DS (2002) Traumatic aortic injury: an imaging review. Emerg Radiol 9:13–20PubMedGoogle Scholar
  42. 42.
    Heckman SR, Trooskin SZ, Burd RS (2005) Risk factors for blunt thoracic aortic injury in children. J Pediatr Surg 40:98–102PubMedCrossRefGoogle Scholar
  43. 43.
    Lowe LH, Bulas DI, Eichelberger MD et al (1998) Traumatic aortic injuries in children: radiologic evaluation. AJR 170:39–42PubMedGoogle Scholar
  44. 44.
    Mirvis SE, Bidwell JK, Buddemeyer EU et al (1987) Value of chest radiography in excluding traumatic aortic rupture. Radiology 163:487–493PubMedGoogle Scholar
  45. 45.
    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 30:277–282PubMedCrossRefGoogle Scholar
  46. 46.
    Anderson SA, Day M, Chen MK et al (2008) Traumatic aortic injuries in the pediatric population. J Pediatr Surg 43:1077–1081PubMedCrossRefGoogle Scholar
  47. 47.
    Demetriades D, Velmahos GC, Scalea TM et al (2008) Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma 64:1415–1418PubMedCrossRefGoogle Scholar
  48. 48.
    Lomoschitz FM, Eisenhuber E, Linnau KF et al (2003) Imaging of chest trauma: radiological patterns of injury and diagnostic algorithms. Eur J Radiol 48:61–70PubMedCrossRefGoogle Scholar
  49. 49.
    John V, Mathai J, Chacko J et al (2006) Tracheoesophageal fistula in a child after blunt chest trauma. J Pediatr Surg 41:E27–E29PubMedCrossRefGoogle Scholar
  50. 50.
    Sakamoto Y, Seki Y, Tanaka N et al (2000) Tracheoesophageal fistula after blunt chest trauma: successful diagnosis by computed tomography. Thorac Cardiovasc Surg 48:102–103PubMedCrossRefGoogle Scholar
  51. 51.
    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.e2CrossRefGoogle Scholar
  52. 52.
    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 40:61–67PubMedCrossRefGoogle Scholar
  53. 53.
    Ozay B, Ozer N, Ketenci B et al (2008) Unsuspected location of a ventricular septal defect after blunt chest trauma. Thorac Cardiovasc Surg 56:110–111PubMedCrossRefGoogle Scholar
  54. 54.
    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.e5CrossRefGoogle Scholar
  55. 55.
    Asai Y, Kurimoto Y (2007) Impending rupture of a blunt trauma-induced left ventricular aneurysm: report of a case. Surg Today 37:971–973PubMedCrossRefGoogle Scholar
  56. 56.
    Eren S, Kantarci M, Okur A (2006) Imaging of diaphragmatic rupture after trauma. Clin Radiol 61:467–477PubMedCrossRefGoogle Scholar
  57. 57.
    Ramos CT, Koplewitz BZ, Babyn PS et al (2000) What have we learned about traumatic diaphragmatic hernias in children. J Pediatr Surg 35:601–604PubMedCrossRefGoogle Scholar
  58. 58.
    Soundappan SV, Holland AJ, Cass DT et al (2005) Blunt traumatic diaphragmatic injuries in children. Injury 36:51–54PubMedCrossRefGoogle Scholar
  59. 59.
    Iochum S, Ludig T, Walter F et al (2002) Imaging of diaphragmatic injury: a diagnostic challenge. Radiographics 22(Spec No):S103–S116PubMedGoogle Scholar
  60. 60.
    Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR 184:24–30PubMedGoogle Scholar
  61. 61.
    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 37:874–877PubMedCrossRefGoogle Scholar
  62. 62.
    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 52:776–784PubMedGoogle Scholar
  63. 63.
    Testerman GM (2006) Surgeon-performed ultrasound in the diagnosis and management of pericardial tamponade in a 20-month-old blunt injured toddler. Tenn Med 99:37–38PubMedGoogle Scholar
  64. 64.
    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 25:1263–1268PubMedGoogle Scholar
  65. 65.
    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 190:1591–1598PubMedCrossRefGoogle Scholar
  66. 66.
    Donnelly LF (2005) Reducing radiation dose associated with pediatric CT by decreasing unnecessary examinations. AJR 184:655–657PubMedGoogle Scholar
  67. 67.
    Brenner D, Elliston C, Hall E et al (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR 176:289–296PubMedGoogle Scholar
  68. 68.
    Mazrani W, McHugh K, Marsden PJ (2007) The radiation burden of radiological investigations. Arch Dis Child 92:1127–1131PubMedCrossRefGoogle Scholar
  69. 69.
    Paterson A, Frush DP (2007) Dose reduction in paediatric MDCT: general principles. Clin Radiol 62:507–517PubMedCrossRefGoogle Scholar
  70. 70.
    Hall EJ, Brenner DJ (2008) Cancer risks from diagnostic radiology. Br J Radiol 81:362–378PubMedCrossRefGoogle Scholar
  71. 71.
    Hall EJ (2002) Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 32:700–706PubMedCrossRefGoogle Scholar
  72. 72.
    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 39:492–499PubMedCrossRefGoogle Scholar
  73. 73.
    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 181:321–329PubMedGoogle Scholar
  74. 74.
    Li J, Udayasankar UK, Toth TL et al (2007) Automatic patient centering for MDCT: effect on radiation dose. AJR 188:547–552PubMedCrossRefGoogle Scholar
  75. 75.
    Kalender WA, Buchenau S, Deak P et al (2008) Technical approaches to the optimisation of CT. Phys Med 24:71–79PubMedCrossRefGoogle Scholar
  76. 76.
    Huda W, Vance A (2007) Patient radiation doses from adult and pediatric CT. AJR 188:540–546PubMedCrossRefGoogle Scholar
  77. 77.
    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 233:515–522PubMedCrossRefGoogle Scholar
  78. 78.
    Smith AB, Dillon WP, Lau BC et al (2008) Radiation dose reduction strategy for CT protocols: successful implementation in neuroradiology section. Radiology 247:499–506PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Michael A. Moore
    • 1
  • E. Christine Wallace
    • 2
  • Sjirk J. Westra
    • 1
    Email author
  1. 1.Department of RadiologyMassachusetts General Hospital and Harvard Medical SchoolBostonUSA
  2. 2.Department of RadiologyUMass Memorial Medical Center and University of Massachusetts Medical SchoolWorcesterUSA

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