Delayed Presentation of Small Bowel Injury Following Extraperitoneal Ballistic Injury

Lack of peritoneal violation has been a strong tenet of nonoperative management for extraperitoneal penetrating injuries. There have been reports of intraperitoneal injuries without peritoneal violation in adult trauma literature. Such reports are scarce in pediatric trauma. We report delayed presentation of a small bowel injury in a 4-year-old male following extraperitoneal ballistic injury. No peritoneal violation was noted on wound exploration allowing conservative management. Patient developed abdominal distention on postoperative day 1, and radiologic imaging showed intraperitoneal air warranting an exploratory laparotomy. Intraperitoneal injuries without peritoneal violation have been attributed to the transmission of kinetic energy through the extraperitoneal tissue. Clinical judgment, physical exam, and radiologic adjuncts are of the utmost importance in management. Given our findings, extraperitoneal penetrating injuries certainly warrant extended observation of the patient.