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Chest injuries in childhood
D K Nakayama1, M L Ramenofsky, M I Rowe
1Department of Pediatric Surgery, Children's Hospital, Pittsburgh, Pennsylvania.
Insights
Pediatric chest trauma is predominantly blunt, often occurring without rib fractures. Associated injuries significantly increase severity and hospitalization, but ventilatory support is rarely needed and typically brief.
Area of Science:
- Pediatric Trauma Surgery
- Thoracic Injury Management
- Childhood Injury Epidemiology
Background:
- Childhood thoracic trauma presents unique challenges due to anatomical and injury mechanism differences.
- Blunt trauma, particularly from traffic accidents, is the leading cause of chest injuries in children.
- Significant intrathoracic injuries can occur without obvious signs like rib fractures.
Purpose of the Study:
- To characterize the scope and consequences of chest injuries in pediatric patients.
- To identify factors influencing injury severity, treatment needs, and outcomes in children with thoracic trauma.
- To compare the incidence of specific injuries and interventions in children versus adults.
Main Methods:
- Retrospective review of 105 pediatric patients (1 month to 17 years) admitted with chest injuries between 1981 and 1988.
- Analysis of injury mechanisms, types of thoracic and associated injuries, interventions (e.g., intubation, ventilation), and outcomes (hospitalization duration, mortality).
- Correlation of injury severity scores (e.g., Injury Severity Score, Chest Abbreviated Injury Scale) with mortality and other outcomes.
Main Results:
- Nearly all injuries (97.1%) were blunt, with traffic accidents being common (over 50%).
- Rib fractures (49.5%) and pulmonary contusions (53.3%) were frequent, but significant injuries occurred without rib fractures in 52% of blunt trauma cases.
- Associated injuries (head, abdominal, orthopedic) were present in 68.6%; intubation was needed in 20%. Longer hospitalizations and higher Injury Severity Scores were linked to associated injuries, intubation, pneumothorax, and hemothorax.
Conclusions:
- Blunt mechanisms dominate pediatric chest trauma, frequently involving injuries beyond rib fractures.
- While associated injuries and specific thoracic injuries (pneumothorax, hemothorax) worsen outcomes, the need for prolonged ventilatory support is uncommon.
- Severe injuries like aortic transection and flail chest are rare in children, and thoracotomy is infrequently required.
Abstract:
Differences in anatomy and mechanisms of injury are believed to contribute to the unique response of children to thoracic trauma. To characterize the scope and consequences of childhood chest injury, we reviewed the records of 105 children (ages 1 month to 17 years, mean 7.6 years) with chest injuries admitted to a level I pediatric trauma center from 1981 to 1988. Nearly all injuries (97.1%) were due to blunt trauma, and more than 50% were traffic related. Rib fractures, commonly multiple, and pulmonary contusions occurred with nearly equal frequency (49.5% and 53.3%, respectively), followed by pneumothorax (37.1%) and hemothorax (13.3%). One fourth of all pneumothoraces were under tension. Significant intrathoracic injuries occurred without rib fractures in 52% of cases with blunt trauma. Associated head, abdominal, and orthopedic injuries were present in 68.6% of children reviewed. One in five received endotracheal intubation and ventilatory support for 1 to 109 days. Presence or absence of head injury neither increased the need for respiratory support (29.4% vs. 17.2%, respectively; p = 0.24) nor affected the duration of support for those who were ventilated (6.8 +/- 8.9 days vs. 3.3 +/- 2.6 days, excluding one ventilator-dependent head-injured patient and five early deaths). The presence of associated injuries, intubation, and pneumothorax or hemothorax all resulted in significantly longer hospitalizations and more severe injury as measured by Injury Severity Score (ISS). Age, rib fracture, and contusion had no effect. Rarely encountered were ruptured diaphragm (2 cases), transection of the aorta (1), major tracheobronchial tears (3), flail chest (1), and cardiac contusion (2). Only two of the three children with penetrating injuries and three of the 83 (3.6%) with blunt injuries underwent chest operations. Six children (7%) died, one from a penetrating injury and five from blunt mechanisms. Chest Abbreviated Injury Scale (AIS) and ISS correlated significantly with mortality; age and head AIS did not. Rib fractures, lung contusions, and associated head, abdominal, and skeletal injuries are common because of the predominance of blunt-injury mechanisms. Nearly one half of chest injuries occurred without rib fractures. The need for ventilatory support is uncommon; when required, its duration is generally brief. Aortic transection, flail chest, and penetrating injuries more frequently encountered in adults and are uncommon in children. Thoracotomy generally is not required.(ABSTRACT TRUNCATED AT 400 WORDS)