AJR:192, May 2009 1179

that can divert attention from the abdomen,

making diagnosis and triage more difcult
and complex. Therefore, diagnostic imaging
plays an important role in the evaluation of
injured children.
Diagnostic Imaging
The indications for imaging after blunt
trauma are physical examination or labora-
tory ndings suggestive of abdominal injury
including hematuria, abdominal bruising or
ecchymosis, abdominal distention, abdomi-
nal pain, absence of bowel sounds, vomit-
ing, decreased hematocrit, and blood from
the rectum or nasopharyngeal tube aspirate.
The most common indication for abdominal
imaging after trauma in children is hematuria
[5]. Several points to be noted regarding he-
maturia and abdominal injury include, rst,
most children with hematuria do not have uri-
nary tract injury; second, nonurinary tract
injury is observed more frequently than uri-
nary tract injury in children with hematuria;
and, third, asymptomatic hematuria is a low-
risk indicator for abdominal injury [5, 6].
If clinical examination could accurately
predict which children have abdominal in-
juries, there would be no need for diagnos-
tic tests. However, certain clinical variables
have been associated with a higher risk of
abdominal injury including gross hematu-
ria, abdominal tenderness, ecchymoses, and
a low trauma score [2, 7, 8]. Lap-belt ec-
chymoses represent an important high-risk
marker for injury [9]. These linear ecchy-
moses across the lower abdomen or ank are
seen in belted passengers involved in motor
vehicle crashes. The ecchymoses show the
Imaging Children with
Abdominal Trauma
Carlos J. Sivit
1
Sivit CJ
1
Department of Radiology, Division of Pediatric
Radiology, Rainbow Babies and Childrens Hospital,
11100 Euclid Ave., Cleveland, OH 44106-5056.
Address correspondence to C. J. Sivit
(Carlos.Sivit@UHhospitals.org).
Pedi at ri c I magi ng Revi ew
CME
This article is available for CME credit. See www.arrs.
org for more information.
AJR 2009; 192:11791189
0361803X/09/19251179
American Roentgen Ray Society
T
rauma is a leading cause of mor-
bidity and mortality in childhood,
resulting in more than 1.5 mil-
lion injuries, 500,000 hospital
admissions, and 20,000 deaths per year [1].
Approximately 80% of injuries are due to
blunt force trauma. The abdomen is the sec-
ond most common site of injury. The most
common reported mechanism for abdominal
injury is motor vehicle crashes, followed by
automobile-versus-pedestrian injuries and
falls [2]. Other frequently associated mecha-
nisms of injury include handlebar injuries
from bicycles, all-terrain vehicle crashes,
and sports. In young children, injuries may
also result from intentional trauma.
There are important physiologic differ-
ences between children and adults after blunt
abdominal trauma. Children have smaller
blood vessels with enhanced vasoconstric-
tive response. Thus bleeding associated with
solid viscus injury usually stops spontane-
ously regardless of injury grade. As a result,
most solid viscus injury in children can be
successfully managed nonoperatively. In a
study of 122 children with isolated hepatic
or splenic injury over a 10-year period, only
3% of hepatic and 2% of splenic injuries re-
quired laparotomy [3]. More recently in a
multicenter study of 316 children with isolat-
ed grade IIV hepatic or splenic injury, only
1% required laparotomy [4].
The clinical evaluation of children with
potential blunt abdominal injury presents a
difcult and challenging task. There is much
concern about the reliability of the abdomi-
nal examination in preverbal children. In ad-
dition, multisystem injuries are often present
Keywords: abdominal injury, abdominal trauma,
emergency radiology, pediatric imaging, trauma
DOI:10.2214/AJR.08.2163
Received November 24, 2008; accepted without revision
November 25, 2008.
F
O
C
U
S

O
N
:
OBJECTIVE. Trauma is a leading cause of morbidity and mortality in children. The abdomen
is the second most common site of injury. This article discusses abdominal trauma in children.
CONCLUSION. The clinical evaluation of children with potential blunt abdominal in-
jury presents a challenging task. Therefore, imaging plays an essential role in the evaluation
of such children.
Sivit
Imaging Children with Abdominal Trauma
Pediatric Imaging
Review
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1180 AJR:192, May 2009
Sivit
pattern of the lap belt. They are associated
with a complex of injury to the lumbar spine,
bowel, and bladder accounting for most inju-
ries to belted motor vehicle passengers [9].
Two clinical indications that have a low
diagnostic yield in predicting injury are as-
ymptomatic hematuria and neurologic im-
pairment in the absence of abdominal signs
and symptoms [5, 10]. Abdominal injuries in
both of these groups have been shown to be
uncommon and minor in signicance.
CT
CT is the imaging method of choice in the
evaluation of abdominal and pelvic injuries
after blunt trauma in hemodynamically sta-
ble children. Unstable patients need to be
stabilized before CT or to proceed directly to
surgery. If they require rapid imaging, hemo-
dynamically unstable children can be exam-
ined at the bedside with sonography. Evalu-
ation with CT allows accurate detection and
quantication of injury to solid and hollow
viscera. CT also identies and quanties in-
traperitoneal and extraperitoneal uid and
blood and active hemorrhage. CT can help
prioritize optimal management by diagnos-
ing the major or most life-threatening site of
hemorrhage or injury. In addition, CT shows
associated bone injury to the ribs, spine, and
pelvis. An important issue that should not be
overlooked when evaluating the impact of
CT as the primary screening technique for
children after abdominal trauma relates to
the value of a normal examination: A nor-
mal CT examination may prevent unneces-
sary surgical exploration owing to its ability
to provide a comprehensive evaluation of the
abdomen and pelvis.
CT scans are obtained from the lower chest
to the symphysis pubis. Monitoring devices
and metallic leads should be moved from the
scanning plane because they will yield streak
artifacts. Gastric distention should be re-
lieved because artifacts may arise from air
uid interfaces. Sedation is rarely required
before CT because advances in CT technol-
ogy have greatly reduced scanning times.
However, excessive patient motion will result
in image degradation. Therefore, in select in-
stances, a short-acting sedative may be nec-
essary to obtain diagnostic images.
The use of IV contrast material by rap-
id bolus injection is essential to maximize
opacication of solid viscera and ensure ade-
quate injury detection. We administer 2 mL/
kg with a maximum amount of 120 mL. IV
contrast material is necessary because solid
viscus laceration or hematoma may be rela-
tively isodense to unenhanced or poorly en-
hanced solid viscera. In addition, the use of
IV contrast material allows the detection of
active hemorrhage. Scanning of the pelvis
should be delayed by several minutes after
IV contrast injection to optimize bladder dis-
tention by IV contrast material. If a renal pa-
renchymal injury is noted at initial scanning,
delayed scanning through the kidneys is also
helpful in the detection of renal collecting
system injury.
There is controversy regarding the use of
oral contrast material after blunt trauma [11,
12]. Potential advantages to the use of oral
contrast material include, rst, enhanced de-
tection of small intramural or mesenteric he-
matomas; second, improved delineation of
the pancreas from surrounding bowel; and,
third, detection of oral contrast extravasa-
tion as a sign of bowel rupture. Potential dis-
advantages include time constraints and de-
creased bowel motility in injured children,
which limits the ability to opacify much be-
yond the proximal small bowel; creation of
artifacts from aircontrast interfaces in the
stomach; and the possibility of vomiting
with resultant aspiration. If oral contrast ma-
terial is used, dilute (2%) water-soluble con-
trast material should be administered at least
30 minutes before scanning.
Sonography
Sonography has limited utility in the as-
sessment of pediatric abdominal trauma. It
has been primarily used in the detection of
hemoperitoneum in trauma patients. How-
ever, the presence of hemoperitoneum in the
hemodynamically stable child typically has
limited impact on management decisions. In
addition, sonography has been shown to have
variable sensitivity and specicity in the de-
tection of hemoperitoneum [1316]. A me-
ta-analysis of abdominal sonography in pe-
diatric trauma patients showed a sensitivity
of 80% (95% CI, 7684%) and specicity
of 96% (95% CI, 9597%) [17]. Sonography
has other important limitations in the eval-
uation of the abdomen in injured children.
First, it does not provide any diagnostic in-
formation regarding injury to the pelvis or
lumbar spine. Moreover, sonography cannot
be used in the diagnosis of hollow viscus in-
jury. Finally, sonography has been shown to
miss approximately one fourth to one third
of solid viscus injuries [18, 19]. Neverthe-
less, sonography has an important role in the
assessment of the hemodynamically unstable
patient because it can be rapidly performed
at the bedside before taking the patient to the
operating room. In this role, it can serve as
a fast, noninvasive replacement of diagnostic
peritoneal lavage.
The primary sonographic technique used
for the evaluation of blunt abdominal trau-
ma has been described as focused abdominal
sonography for trauma (FAST). The focus
of this technique is to evaluate the right up-
per quadrant, left upper quadrant, and pelvis
for free peritoneal uid. If possible, the pel-
vis should be examined when the bladder is
full or nearly full. However, there is no uni-
form approach to the sonographic technique
and some examiners also perform a more
comprehensive assessment of the pleural and
pericardial spaces and solid organs including
the liver, spleen, pancreas, and kidneys.
Abdominal Injury
Hepatic Injury
The liver is frequently injured viscus af-
ter blunt trauma. In various series it is either
the most commonly injured or second most
commonly injured solid viscera after blunt
trauma. Associated abdominal visceral inju-
ries are seen frequently. Splenic injuries oc-
cur in nearly one third of patients with hepat-
ic injury. Most hepatic injury occurs in the
posterior segment of the right lobe [20]. The
effects of blunt force are maximized in this
location because the posterior right lobe is
xed by the coronary ligaments, which lim-
its its movement while the rest of the liver is
free to move. This results in shearing forc-
es centered in the posterior segment of the
right lobe.
The principal types of liver injury are lac-
eration, hematoma, and vascular injuries.
Lacerations appear as linear or branching
low-attenuation areas (Fig. 1). Lacerations
are often associated with hematomas. He-
patic hematomas may be parenchymal, sub-
capsular, or parenchymal and subcapsular.
Subcapsular hematomas cause direct com-
pression of underlying liver parenchyma,
which allows differentiation from peritoneal
uid surrounding the liver (Fig. 2). Vascular
hepatic injury is rare in children. Partial he-
patic devascularization can result from inju-
ry affecting the dual blood supply of the liv-
er. At CT, devascularized segments appear
as low-attenuation areas that may be wedged
shaped and may fail to show contrast en-
hancement (Fig. 3).
The liver is surrounded by a thin capsule
that, in turn, is covered by peritoneal reection
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AJR:192, May 2009 1181
Imaging Children with Abdominal Trauma
of thin connective tissue. The presence of he-
moperitoneum associated with hepatic injury
principally relates to whether a laceration ex-
tends to the liver surface and whether the liv-
er capsule remains intact at the site of injury.
Hepatic injury is associated with hemoperi-
toneum in approximately two thirds of cases
[21, 22]. Associated hemoperitoneum may be
seen throughout the greater peritoneal cavity.
Often the largest uid pockets are located in
the pelvis.
Hepatic injury may not be associated with
intraperitoneal hemorrhage if the injury does
not extend to the surface of the liver, if the
hepatic capsule is not disrupted, or if there is
extension to the liver surface in the bare area
of the liver, which is devoid of peritoneal re-
ection [23]. The bare area is the site of in-
sertion of the coronary ligaments. The bare
area of the liver is in continuity with the ret-
roperitoneum. Injury extending to the bare
area may lead to associated retroperitoneal
hemorrhage, with blood often surrounding
the right adrenal gland or extending into the
anterior pararenal space (Fig. 4).
Circumferential zones of periportal low
attenuation may be seen in the liver after
trauma [24, 25] (Fig. 5). They have also been
reported in several nontraumatic conditions.
The presence of these low-attenuation zones
does not indicate hepatic injury. They are
likely due to elevated central venous pres-
sures and resultant intravascular third-space
uid losses after vigorous uid resuscitation
[25]. The uid extends to the periportal lym-
phatics, which are located within the portal
triad. Thus, the periportal zones of low atten-
uation likely result from distention of these
lymphatics.
A number of grading scales to quantify the
severity of hepatic injury have been proposed.
The scales emphasize the anatomic extent of
the injury including capsular integrity, the ex-
tent of subcapsular collection, the extent of
parenchymal disruption, and the state of the
A
Fig. 212-year-old boy with subcapsular hematoma of liver.
A, Contrast-enhanced CT scan through upper abdomen shows laceration extending to periphery of liver with
associated subcapsular hematoma.
B, CT scan obtained 2 cm below A shows inferior extension of subcapsular hematoma. Note compression of
underlying hepatic parenchyma.
B
Fig. 18-year-old boy with hepatic laceration.
Coronal reformation of contrast-enhanced CT scan
through upper abdomen shows complex hepatic
laceration.
Fig. 35-year-old boy with vascular injury in
posterior segment of right hepatic lobe. Contrast-
enhanced CT scan through upper abdomen shows
absence of contrast enhancement in posterior
segment of right hepatic lobe.
Fig. 411-year-old girl with hepatic laceration
through bare area. Contrast-enhanced CT scan
through upper abdomen shows laceration extending
into bare area of liver.
Fig. 58-year-old girl with periportal low-
attenuation zones. Contrast-enhanced CT scan
through liver shows circumferential periportal low-
attenuation zones surrounding main portal vein. Note
there is right-sided periadrenal hematoma. Also note
small amount of free peritoneal air anterior to liver.
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1182 AJR:192, May 2009
Sivit
vascular pedicle. The most widely used grad-
ing scale was developed by the American As-
sociation for the Surgery of Trauma (AAST)
[26]. In children, these scales are not predic-
tive of a need for operative management be-
cause most hepatic injuries can be success-
fully managed nonoperatively regardless of
the severity because bleeding typically stops
spontaneously. In various reports, between
1% and 3% of children with hepatic injury
required surgical hemostasis [4, 27]. The
most common cause for failed nonoperative
management is ongoing bleeding. However,
the injury grading scales are often used in
patient management decisions including the
duration and intensity of hospitalization and
activity restriction.
Splenic Injury
Splenic injury is common after blunt trau-
ma. It is also frequently associated with oth-
er organ injuries. Splenic lacerations have a
variable appearance ranging from linear to
a branching pattern. Because the spleen is
much smaller than the liver, complex inju-
ry results in shattering or fragmentation of
the organ (Fig. 6). Associated intraparenchy-
mal or subcapsular hematoma may be pres-
ent (Fig. 7). As with hepatic injury, associat-
ed intraperitoneal hemorrhage is not always
present. If the splenic capsule remains intact,
there is no associated hemoperitoneum. The
absence of hemoperitoneum is observed in
approximately 25% of splenic injuries [21,
22]. Blood can also track into the retroperito-
neum after splenic injury [28]. This typical-
ly occurs with injury extending to the splen-
ic hilum. In these instances, blood extends
along the splenorenal ligament into the an-
terior pararenal space surrounding the pan-
creas (Fig. 8).
Various injury grading scales have been
reported for quantifying injury to the spleen.
The most widely used grading scale was de-
veloped by the AAST [26]. As is true for he-
patic injury, these scales are not measures of
required surgical treatment because bleeding
typically stops spontaneously and nonopera-
tive management is successful in most splen-
ic injuries. The injury grade is often used for
nonoperative management decisions similar
to its use in hepatic injury.
Pitfalls that may result in the false-posi-
tive diagnosis of splenic injury include het-
erogeneous enhancement early during the
bolus and splenic clefts. Splenic clefts can be
differentiated from lacerations: Clefts have
a smooth contour, whereas lacerations have
irregular contours and are often associated
with hematoma or uid around the spleen.
Renal Injury
The kidney is the third most frequently in-
jured abdominal viscera in children. Renal pa-
renchyma injury typically results from direct
impact, whereas vascular and collecting sys-
tem injuries usually result from deceleration.
The most common renal injury is the paren-
chymal contusion, which is manifested on CT
by a focal or diffuse region of delayed contrast
enhancement (Fig. 9). The contusion repre-
sents an organ bruise characterized by micro-
scopic areas of hemorrhage and surrounding
edema. The involved kidney may also appear
larger than the uninvolved kidney on CT as a
result of the associated edema. Renal lacera-
tions appear as linear low-attenuation areas
in the parenchyma. Deep lacerations may in-
volve the renal collecting system.
Renal injury may be complicated by peri-
renal hematoma, which may be subcapsular
or perinephric. These two types of hemato-
ma can be differentiated on the basis of CT
features: A subcapsular hematoma is limited
in its extension by the renal capsule and will
A
Fig. 614-year-old boy with shattered spleen.
A and B, Contrast-enhanced CT scans through upper abdomen (A) and 2 cm lower (B) show shattered spleen.
B
Fig. 712-year-old boy with splenic laceration and
associated intraparenchymal hematoma. Contrast-
enhanced CT scan through upper abdomen shows
splenic laceration and associated intraparenchymal
hematoma.
Fig. 815-year-old boy with splenic injury and
retroperitoneal extension of hemorrhage. Contrast-
enhanced CT scan through upper abdomen shows
splenic laceration associated with blood in anterior
pararenal space surrounding pancreas.
Fig. 910-year-old girl with renal contusion.
Contrast-enhanced CT scan through mid abdomen
shows rounded focus of low attenuation in midpole of
left kidney indicative of contusion.
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AJR:192, May 2009 1183
Imaging Children with Abdominal Trauma
therefore exert greater mass effect on renal
parenchyma (Fig. 10), whereas a perinephric
hematoma is distributed throughout the peri-
renal space and typically shows less mass ef-
fect on renal parenchyma [29] (Fig. 11).
Renal collecting system injury results in
urinary extravasation of IV contrast medium
[30]. Delayed scanning 1015 minutes af-
ter IV contrast administration may be use-
ful in detecting such extravasation [30] (Fig.
12). Urine leakage typically remains en-
capsulated in the perirenal space and is re-
ferred to as a urinoma. Occasionally, hem-
orrhage or urinary extravasation may extend
into the pelvis owing to direct communica-
tion between the perirenal space in the abdo-
men and the prevesical extraperitoneal space
in the pelvis in some individuals [31]. Renal
collecting system injury is typically man-
aged nonoperatively, particularly if the leak
is conned to the perirenal space. Occasion-
ally, urinary tract obstruction requiring sur-
gical repair may result [29].
Renal infarction occurs after laceration of
a main or segmental renal arterial branch.
Injury to a segmental renal artery produces
a segmental renal infarct. The appearance
at CT is that of a peripheral wedged-shaped
area of nonenhancing parenchyma [29, 32]
(Fig. 13). Renal infarction is typically man-
aged nonoperatively and results in a focal
area of renal scarring. Injury to the main re-
nal artery results in devascularization of the
entire kidney (Fig. 14). This is the most se-
vere form of renal injury. This injury must
be treated promptly because permanent, pro-
gressive loss of renal function begins 2 hours
after injury [33].
Pancreatic Injury
Pancreatic injury is relatively uncom-
mon in children. Isolated injuries are rare.
Most pancreatic injuries are seen in associa-
tion with hepatic, splenic, or duodenal inju-
ry. Injury to the body of the pancreas typi-
cally results from direct compression of the
gland against the vertebral column, whereas
injury to the head or tail of the pancreas re-
sults from a blow to the ank. Direct signs of
injury may be difcult to identify owing to
the small size of the gland, the paucity of sur-
rounding fat, and the minimal separation of
fracture fragments. Pancreatic laceration ap-
pears as linear low-attenuation parenchymal
areas. Transection results in complete sepa-
ration of pancreatic fragments (Fig. 15). Un-
less the two edges of a fracture are separated
by low-attenuation uid or hematoma, the di-
agnosis may be difcult to recognize at CT.
The best indicator of pancreatic injury at CT
is unexplained peripancreatic uidthat is,
uid in the anterior pararenal space or lesser
sac [34, 35] (Fig. 16). This nding may be
seen more often than the actual laceration.
When uid collects in the anterior pararenal
space, it may also dissect between the pan-
creas and the splenic vein [35, 36] (Fig. 16).
Pancreatic injury is only one cause of uid
in the anterior pararenal space. Other causes
include third-space intravascular uid loss,
blood extending from injury to the spleen or a
bare area of the liver, blood or bowel contents
from a duodenal injury, and blood or urine
dissecting from a renal injury after disruption
of the renal fascia [28, 37, 38].
Additional CT signs of pancreatic injury
include focal or diffuse gland enlargement,
stranding of peripancreatic or mesenteric fat,
thickening of the anterior renal fascia, and
free peritoneal uid (Fig. 17). These ndings
are typically due to a secondary pancreati-
tis that develops after injury. Trauma is the
leading cause of pancreatitis in children.
Pancreatic injury can be complicated by
peripancreatic uid collections, which may
evolve into pancreatic pseudocysts. Approxi-
mately one half of focal uid collections that
develop after pancreatic injury evolve into
pseudocysts, whereas the remaining one half
spontaneously resolve [37]. The most com-
mon location for pseudocyst formation in ei-
ther intrapancreatic or peripancreatic in the
anterior pararenal space or lesser sac (Fig. 18).
However, pseudocysts may develop anywhere
Fig. 1012-year-old boy with subcapsular renal
hematoma. Contrast-enhanced CT scan through
mid abdomen shows large left-sided subcapsular
hematoma compressing renal parenchyma.
Fig. 1110-year-old girl with perinephric hematoma.
Sagittal reformation of contrast-enhanced CT
scan through mid abdomen shows renal laceration
associated with perinephric hematoma distributed
through perirenal space.
A
Fig. 1214-year-old boy with renal collecting system injury.
A, Contrast-enhanced CT scan through mid abdomen shows left renal laceration with surrounding perinephric
hematoma.
B, Delayed image obtained 5 minutes after A shows extravasation of IV contrast material into perirenal space.
B
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1184 AJR:192, May 2009
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in the abdomen or pelvis. Approximately one
half of pseudocysts resolve spontaneously,
and the remaining require percutaneous or
surgical drainage.
Identication of possible pancreatic duct
disruption may impact management, although
there are currently divergent opinions regard-
ing the management of ductal injury. Nonop-
erative management of most pancreatic inju-
ryeven when there is involvement of the
pancreatic ducthas been proven successful
by some [39, 40]. Others believe that a distal
pancreatectomy for transection to the left of
the spine is the treatment of choice because
it is denitive with an acceptable morbidity
[41]. CT may show pancreatic duct injury di-
rectly. Injury to the duct can also be predicted
at CT by evaluating the depth of laceration.
Further assessment of the pancreatic duct
can also be performed with MR cholangiopan-
creatography (MRCP) and ERCP. MRCP has
the advantage of being noninvasive and fast-
er than ERCP. In addition, MRCP is helpful
in further dening pancreatic injury and asso-
ciated uid collections [42]. MR pancreato-
grams are acquired using heavily T2-weight-
ed sequences [43]. Pancreatic parenchyma is
best assessed using T1- and T2-weighted se-
quences with fat suppression [43].
Active Hemorrhage
Children are typically excluded from CT
if ongoing bleeding is clinically evident.
Occasionally, CT may show active hemor-
rhage in children who appear hemodynami-
cally stable. The amount of hemoperitoneum
noted on CT is not a measure of ongoing
hemorrhage [21]. Rather, it reects the cu-
mulative amount of bleeding occurring be-
tween the time of injury and the time that CT
was performed.
The only sign of active hemorrhage at CT
is a contrast blush, which is dened as high-
attenuation areas (> 90 HU) after IV contrast
Fig. 1311-year-old girl with segmental renal infarct.
Coronal reformation of contrast-enhanced CT scan
through mid abdomen shows multiple peripheral
wedged-shaped renal parenchymal defects.
Fig. 1415-year-old boy with vascular injury of left
kidney. Contrast-enhanced CT scan through mid
abdomen shows devascularization of left kidney after
left renal artery avulsion.
Fig. 1511-year-old boy with pancreatic transection.
Contrast-enhanced CT scan through upper abdomen
shows pancreatic transection at junction of head
and body.
Fig. 1610-year-old girl with pancreatic injury and
associated peripancreatic uid. Contrast-enhanced
CT scan through upper abdomen shows uid is in
anterior pararenal space surrounding pancreas.
Also note uid dissecting between splenic vein and
pancreas.
Fig. 1712-year-old boy with acute pancreatitis
after pancreatic trauma. Contrast-enhanced CT
scan through upper abdomen shows stranding of
peripancreatic fat and ill-denition of pancreatic
borders.
A
Fig. 1811-year-old boy with pancreatic pseudocyst.
A, Contrast-enhanced CT scan through upper abdomen shows laceration through head of pancreas.
B, Follow-up CT scan obtained 5 weeks after A shows focal uid collection representing pancreatic pseudocyst
is in head of pancreas and is extending into anterior pararenal space.
B
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AJR:192, May 2009 1185
Imaging Children with Abdominal Trauma
enhancement [44, 45]. However, a contrast
blush alone is insufcient to diagnose active
hemorrhage because it can also be seen with
a contained vascular injury or pseudoaneu-
rysm. Active hemorrhage will appear as a
high-attenuation jet of extravasated IV con-
trast material (Fig. 19) or as high-attenuation
uid in the peritoneum or retroperitoneum
(Fig. 20). A pseudoaneurysm will appear as
a contained high-attenuation collection (Fig.
21). If the blush is surrounded by solid organ
parenchyma, it may be difcult to differen-
tiate a contained from a noncontained col-
lection. In this instance, delayed scanning is
useful. A contained vascular injury will wash
out on delayed imaging, whereas active hem-
orrhage will not wash out. The rate of active
bleeding required for detection at CT is un-
clear. CT is useful in these cases not only in
identifying the active bleeding but also in lo-
calizing the site of hemorrhage.
Most children with active hemorrhage
detected at CT do not require operative in-
tervention, particularly when the active
hemorrhage is within a solid viscus and is
surrounded by organ parenchyma (Fig. 22).
In various reports, 20% or less of children
with hepatic or splenic injury and active
hemorrhage required operative hemostasis
[4648].
Bowel Injury
Bowel injury is uncommon after blunt trau-
ma in children. Injury can result in a partial-
thickness injury that results in intramural he-
matoma or a full-thickness injury that results
in bowel rupture. Associated mesenteric injury
is often present. Most injuries are noted in
children who have been involved in motor ve-
hicle crashes and who display lap-belt ecchy-
moses [9]. The injuries can be seen in children
who are wearing three-point restraints. The
clinical diagnosis of bowel injury may be chal-
lenging. Clinical signs and symptoms may be
absent, minimal, or delayed. Therefore, CT
plays an important role in the diagnosis.
Intramural hematoma results from hem-
orrhage into the bowel wall after a partial-
thickness tear. The most common location
is the duodenum. The injury can usually be
managed nonoperatively. Patients are usual-
ly placed at bowel rest for 1 week or more.
Large hematomas can result in a proximal
small-bowel obstruction. The CT appear-
ance is of focal bowel wall thickening that is
often eccentric (Fig. 23). Large duodenal he-
matomas may appear dumbbell shaped. Nei-
ther extraluminal air nor extravasated con-
trast material should be present.
Bowel rupture most commonly occurs in
the mid to distal small intestine. The most
common site is the jejunum. Extraluminal
air is noted on CT in only approximately one
third to one half of cases [4951]. Review of
the examination at a wide window setting is
helpful in the detection of small amounts of
extraluminal air (Fig. 24). Extravasation of
oral contrast material is rarely seen [50] (Fig.
25). The most frequent CT nding associated
Fig. 198-year-old boy with active hemorrhage.
Contrast-enhanced CT scan through mid abdomen
shows linear high-attenuation collection
representing IV contrast extravasation from splenic
arterial tear.
Fig. 2011-year-old boy with active hemorrhage.
Contrast-enhanced CT scan through pelvis
shows high-attenuation uid representing active
hemorrhage. At surgery tear of right iliac vein was
noted.
Fig. 2112-year-old boy with hepatic
pseudoaneurysm. Contrast-enhanced CT scan
through upper abdomen shows focal, rounded,
enhancing lesion in posterior segment of right
hepatic lobe. Also note large hepatic subcapsular
hematoma.
A
Fig. 2212-year-old girl with active hepatic hemorrhage that did not require laparotomy.
A, Contrast-enhanced CT scan through upper abdomen shows hepatic laceration with focal area of increased
attenuation representing active hemorrhage. Patient was managed nonoperatively.
B, Follow-up CT scan obtained 2 weeks after A shows resolving low-attenuation hematoma within liver.
B
Fig. 238-year-old boy with duodenal hematoma.
Contrast-enhanced CT scan through upper abdomen
shows rounded duodenal hematoma to left of midline.
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1186 AJR:192, May 2009
Sivit
with bowel rupture is unexplained perito-
neal uidthat is, moderate to large amounts
of uid in the absence of solid viscus inju-
ry or pelvic fracture [49] (Fig. 26). Approxi-
mately one half of children with moderate to
large amounts of peritoneal uid as the only
nding on CT after blunt trauma have a bow-
el injury [21]. Additional CT ndings associ-
ated with bowel rupture include abnormally
intense bowel wall enhancement, focal bow-
el wall discontinuity, bowel dilatation, bow-
el wall thickening, and streaky inltration
of mesenteric fat [4951] (Fig. 27). The lat-
ter nding may result from either associated
mesenteric injury or chemical irritation of the
mesentery from spilled intestinal contents.
Bladder Injury
Bladder injury is also uncommon in chil-
dren. Bladder rupture can be intraperito-
neal or extraperitoneal. Combined injuries
may occur. Extraperitoneal bladder rupture
occurs more frequently than intraperitoneal
rupture in children. Intraperitoneal rupture
typically results from shearing of the dis-
tended bladder by a lap belt, whereas extra-
peritoneal rupture often results from lacera-
tion by a bone spicule from a pelvic fracture
[52]. The most common pelvic injuries as-
sociated with extraperitoneal bladder rupture
are obturator ring fractures, pubic symphy-
sis diastasis, sacral fractures, and sacroiliac
joint diastasis.
Bladder distention is essential in the detec-
tion of bladder injury at CT to show extrava-
sation of IV contrast material. This is best
achieved by performing CT cystography [53
55]. CT cystography is performed by admin-
istering dilute iodinated contrast material into
the bladder in a retrograde fashion until the
ow stops followed by clamping of the Fol-
ey catheter [53, 54]. Adequate bladder disten-
tion is critical. Images are then obtained from
the bladder dome through the ischial tuber-
osities. Reformations should be performed in
the coronal and sagittal planes.
The location of extravasated IV contrast
material on CT is useful in differentiating in-
traperitoneal from extraperitoneal bladder
rupture. This distinction is important because
an extraperitoneal bladder rupture is typically
managed nonsurgically, whereas an intraperi-
toneal rupture requires immediate surgical re-
pair. Intraperitoneal uid in the pelvis will be
located in the lateral perivesical spaces supe-
rior to the bladder and anterior to the rectosig-
moid colon (Fig. 28). Extraperitoneal pelvic
uid will be localized in the perivesical space
that surrounds the bladder superiorly and an-
teriorly to the umbilicus and posteriorly be-
hind the rectum (Fig. 29). Thus, if pelvic uid
is noted lateral to the bladder or behind the
rectum, it is extraperitoneal in location. Fluid
superior and anterior to the bladder may be
intraperitoneal or extraperitoneal. If uid su-
perior to the bladder is extraperitoneal, it will
extend superiorly and anteriorly to the level of
the umbilicus. If uid superior to the bladder
Fig. 2410-year-old girl with bowel rupture
associated with extraluminal air. Contrast-enhanced
CT scan through upper abdomen shows extraluminal
air.
Fig. 259-year-old boy with bowel rupture
associated with oral contrast extravasation. CT
scan through upper abdomen shows extravasated
high-attenuation oral contrast material in peritoneal
cavity.
A
Fig. 2612-year-old boy with bowel rupture associated with large amount of unexplained peritoneal uid.
A, Contrast-enhanced CT scan through upper abdomen shows large amount of peritoneal uid in perihepatic
and perisplenic spaces.
B, CT scan through mid abdomen shows large amount of uid in right and left paracolic spaces. Patient did not
have any other abnormalities at CT. At surgery, jejunal rupture was noted.
B
Fig. 279-year-old boy with bowel rupture
associated with bowel wall discontinuity. Contrast-
enhanced CT scan through upper abdomen shows
discontinuity in wall of duodenum indicative of bowel
wall rupture.
Fig. 2815-year-old girl with intraperitoneal bladder
rupture. Contrast-enhanced CT scan through upper
pelvis shows high-attenuation uid in lateral pelvic
recess secondary to intraperitoneal bladder rupture.
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AJR:192, May 2009 1187
Imaging Children with Abdominal Trauma
is intraperitoneal, it will be in a more lateral
location and will typically be contiguous with
uid in the lateral pericolic spaces.
Hypoperfusion Complex
A characteristic complex of ndings on
CT associated with hypovolemic shock in
severely injured children has been charac-
terized as the hypoperfusion complex [38,
56]. Most children with hypovolemic shock
have arterial hypotension on admission [56].
The hypotension may be transiently correct-
ed, and it may be believed that the child is
hemodynamically stable enough to undergo
CT, but many children subsequently devel-
op rapid hemodynamic decompensation. The
transition from a compensated state to non-
compensated shock is usually abrupt.
CT ndings in all children with the hypop-
erfusion complex include diffuse intestinal
dilatation with uid; abnormally intense con-
trast enhancement of the bowel wall, mesen-
tery, kidneys, aorta, and inferior vena cava;
and diminished caliber of the aorta and inferi-
or vena cava [56] (Fig. 30). Variable ndings
include periportal low-attenuation zones; in-
tense adrenal, pancreatic, and mesenteric en-
hancement; decreased pancreatic and splenic
enhancement (Fig. 31); peritoneal and retro-
peritoneal uid; and bowel wall thickening
[38, 57] (Fig. 32). Familiarity with the vari-
able CT ndings that are part of the hypoper-
fusion complex is important to avoid unnec-
essary laparotomy for the mistaken suspicion
of abdominal visceral injury.
The hypoperfusion complex is a mark-
er for a tenuous hemodynamic state and is
a predictor of a poor outcome. The reported
mortality rate in children with this constella-
tion of ndings at CT is more than 80% [56].
Many of these children have severe associ-
ated multisystem injury.
Impact of CT on Clinical
Decision Making
The role of CT in the evaluation of injured
children includes establishing the presence
or absence of visceral and bone injury, iden-
tifying injury requiring close monitoring and
operative intervention, detecting active hem-
orrhage, and estimating associated blood
loss. The use of CT as the primary screening
technique in the assessment of injured chil-
dren, along with improvements in supportive
care, has played a critical role in the success
of nonoperative management of solid viscus
injuries. The rapid evaluation of injured chil-
dren with CT has also resulted in improved
triage and has contributed to reduced mor-
bidity and mortality.
The decision for operative intervention in
the small percentage of children who require
surgical hemostasis is primarily made based
on clinical criteria and not on CT ndings. In
a study of 1,500 consecutive children exam-
ined with CT, only 7% of children with solid
viscus injury underwent laparotomy [27].
The decision for operative intervention in
this small subset of children was based on
clinical criteria in 15 (75%) and CT ndings
in ve (25%) [27]. Therefore, CT primarily
guides nonoperative decisions such as the
duration of hospitalization, intensity of care,
and length of activity restriction. The Ameri-
can Pediatric Surgical Association Trauma
Committee has dened consensus guidelines
for resource utilization in hemodynamically
stable children with isolated hepatic or splen-
ic injury based on CT grading [4]. These
guidelines include ICU stay, length of hospi-
tal stay, and physical activity restriction [4].
A study of 138 consecutive children studied
by CT after blunt trauma showed that CT
ndings changed the diagnoses after initial
clinical assessment in 84% and management
A
Fig. 2912-year-old girl with extraperitoneal bladder
rupture. Contrast-enhanced CT scan through pelvis
shows high-attenuation uid adjacent to right pelvic
side wall and low-attenuation uid posterior to
rectum. These uid collections are extraperitoneal
in location, consistent with extraperitoneal bladder
rupture.
B
Fig. 302-year-old girl with hypoperfusion complex.
A and B, Contrast-enhanced CT scans through upper (A) and mid (B) abdomen show diffuse intestinal dilatation
with uid, intense contrast enhancement of bowel wall, and diminished caliber of great vessels indicative of
systemic hypoperfusion.
Fig. 313-year-old boy with hypoperfusion complex
and absence of pancreatic enhancement. Contrast-
enhanced CT scan through upper abdomen shows
absence of pancreatic enhancement. Pancreas
appeared normal at surgery. Findings were thought to
be secondary to systemic hypoperfusion.
Fig. 322-year-old boy with hypoperfusion complex
associated with free peritoneal uid. Contrast-
enhanced CT scan through mid abdomen shows
diffuse intestinal dilatation with uid, intense
contrast enhancement of bowel wall, and diminished
caliber of great vessels indicative of systemic
hypoperfusion. Also note free peritoneal uid in both
paracolic spaces.
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1188 AJR:192, May 2009
Sivit
plans in 44%, decreasing the intensity of
care in 38% and increasing the intensity of
care in 6% [58].
Solid viscus injury grading at CT has been
shown to be useful for estimating the time
course of healing [5963]. However, follow-
up imaging of solid viscus injury is proba-
bly not necessary in asymptomatic children
for several reasons. First, no injury progres-
sion or complication is noted in most solid
viscus injuries. Second, clinical manage-
ment is rarely altered on the basis of follow-
up imaging.
A negative CT also serves an important
function in excluding an intraabdominal or
pelvic source of blood loss, thus enabling an
early discharge of the child from the hospital
without further observation [64]. The high
negative predictive value of CT indicates
that hospital admission or observation is not
necessary for patients with suspected blunt
abdominal injury and a negative abdominal
CT [64].
CT Dose Reduction Strategies
It is evident that CT is useful in the evalu-
ation and management of children with blunt
abdominal trauma. The concern is that CT
also provides the largest single source of ra-
diation exposure in diagnostic imaging. In
addition, the use of CT in children has in-
creased dramatically in recent years [65]. It
is estimated that more than 4 million CT ex-
aminations are currently performed on chil-
dren in the United States per year [66]. CT
accounts for approximately 510% of the to-
tal imaging procedures and 4070% of the
imaging dose [67]. Children are at greater
risk than adults from a given dose of radi-
ation; they are inherently more radiosensi-
tive and they have more remaining years of
life during which a radiation-induced cancer
could develop. Therefore, we must consider
all possible means by which to reduce the ad-
ministered CT dose.
The most important dose reduction strat-
egy is to reduce utilization. This can be
achieved by, rst, eliminating unnecessary
examinations; second, ensuring availabil-
ity of outside examinations; and, third, de-
creasing or eliminating follow-up CT ex-
aminations. When CT is deemed necessary,
the ALARA (as low as reasonably achiev-
able) principles should be followed rigor-
ously. These principles include limiting the
use of multiphase examinations, collimating
the examination to the area of interest, and
adjusting the technique for the patient size.
The use of automatic exposure control avail-
able on the latest generation of CT scanners
is helpful in optimizing dose reduction [68].
The judicious use of CT and adherence to
ALARA principles are therefore essential to
minimize the population risk.
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F O R Y O U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.
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