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Multimodality Diagnosis of Mesenteric Ischemia

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Delayed Presentation of Small Bowel Injury Following Extraperitoneal Ballistic Injury.

Nehal Ninad¹, Macie Edwards², Paul Parker³

¹Department of Surgery, Atrium Health Navicent, Macon, GA, USA.

The American Surgeon

|February 17, 2023

Summary

Extraperitoneal penetrating injuries in children can cause delayed small bowel injury without obvious peritoneal violation. Extended patient observation is crucial for early detection and management of these subtle but serious pediatric trauma cases.

Keywords:

ballistic injury extended observation intraperitoneal injury without peritoneal violation pediatric trauma penetrating trauma

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Area of Science:

Pediatric Trauma Surgery
Abdominal Injury Management
Ballistic Trauma

Background:

Nonoperative management of extraperitoneal penetrating injuries typically relies on the absence of peritoneal violation.
Intraperitoneal injuries without peritoneal violation are documented in adult literature but are rare in pediatric cases.
This case highlights a potential diagnostic challenge in pediatric trauma patients.

Observation:

A 4-year-old male sustained an extraperitoneal ballistic injury.
Initial wound exploration revealed no peritoneal violation, leading to conservative management.
The patient later presented with abdominal distension and radiographic evidence of intraperitoneal air.

Findings:

A delayed presentation of small bowel injury was diagnosed.
The injury occurred despite the absence of initial peritoneal breach.
Kinetic energy transmission through tissue is a proposed mechanism for such injuries.

Implications:

Extraperitoneal penetrating injuries in children necessitate extended observation periods.
Clinical judgment, physical examination, and imaging are critical for diagnosing occult intraperitoneal injuries.
This case underscores the importance of vigilance in pediatric trauma, even with seemingly minor external wounds.