Teaching Case

Pain and abdominal swelling after a blunt abdominal trauma.

While playing in her garden, a 7-year-old girl brutally collided with a metal post which supported the clothesline. There was no eye-witness. The girl said later that her chest and neck had been wounded. Thereafter, since she had diarrhoea and vomiting, her parents took her to hospital. On arrival, she complained of abdominal pain, she was breathless and cried. Her abdomen was swollen, but neither defence nor contracture was noticed. Vital parameters and blood tests were normal.

Ultrasound was performed and detected free peritoneal fluid, but no other abnormality except a subtle heterogeneity of the splenic parenchyma. The patient was kept under observation. Later, her pain increased further. CT was then performed and showed splenic fracture and fluid in the peritoneal and the left pleural spaces. Conservative management was continued.

48 hours after the accident, 200ml of fluid was removed by left pleural aspiration. A second ultrasound performed the same day showed an obvious splenic fracture.

This report highlights the limited diagnostic capabilities of the first ultrasound examination after blunt abdominal trauma in a child. The poor sensitivity of ultrasound is worsened by the usual conditions of such an examination (a crying restless child with post-traumatic functional ileus, which hinders the sonographic approach). On the other hand, delayed ultrasound is usually very sensitive and often turns out to be sufficient to follow up spleen, renal, pancreatic or liver injuries.

Management of traumatised children remains controversial (1). CT is unquestionably the most effective method. However, it delivers ionising radiation, and requires IV injection and sometimes sedation. Also, CT is not immediately available everywhere, as was the case in this patient; transportation to the CT scanner had to be organised, which carries its own risks.

Given the high frequency of minor trauma in children, it does not appear cost-effective to perform CT on all patients. In our institution, we have chosen to select by ultrasound those children who should benefit from CT (2). When ultrasound, including a colour doppler examination of the liver, spleen and kidneys, is absolutely normal, and there are no risk factors (deceleration, thoraco-abdominal seat belt ecchymosis, multiple trauma), CT is not usually performed in our centre. In cases with any abnormality (fluid, abnormal parenchyma, heterogeneous vasculature, etc), enhanced CT should be performed. This is not applicable to multiple trauma patients or children with cranial wounds; in these patients CT scanning is performed immediately.