Blunt liver and spleen injury rarely require operative intervention in children. A 2014 report noted a significant decrease in the frequency of operations for splenic injury in the United States, from 20% in 2000 to 12% in 2009. A prospective study by the ATOMAC+ Pediatric Trauma Research Network (A+PTRN) suggested an overall NOM failure rate of 8% in SOI, with only 4.4% failing for bleeding. The frequency of failure for isolated SOI failure was even lower at 0% for splenic injury and 3.9% for liver injury. However, most published studies show that hospitals never reached the 95% NOM rate benchmark for stable patients set by APSA in 2000. While some failures may be related to differences in management approach by the type of hospital or provider specialty, concurrent intestinal or pancreatic injury probably prevented a higher rate of successful NOM. ^{, , ,}

Mortality rates associated with splenic and liver injury have decreased over time. Most pediatric trauma deaths in children with blunt abdominal injuries are due to concomitant brain injury and not the liver or spleen injury. In adolescents with blunt SOI without traumatic brain injury, overall mortality in a study of over 9000 patients was 0.9%.

Nonoperative Management

Resource Utilization and Length of Stay

The APSA guideline published in 2000 only applied to hemodynamically stable patients and recommended hospitalization based on grade of injury. In that guideline, the formula for the duration of hospitalization was calculated as the number of hospital days equal to injury grade +1 day. Use of the intensive care unit (ICU) was reserved for grade IV or grade V injuries. However, management based on CT injury grade has been challenged, ^{, , ,} and many centers have adopted the ATOMAC guideline published in 2015 ( Fig. 15.3 ). ^, This guideline was based on the initial work of the group in Arkansas and validated by the group in Kansas City. ^{, ,} While the initial algorithm was based on stability, the current algorithm is based on a clinical suspicion of recent or ongoing bleeding. Over the decades where CT scanning became routine, it was clear that many children had significant injuries to the liver or spleen that were not hemodynamically significant. As such, the 2000 APSA guideline probably led to more ICU days and longer hospitalizations than needed. ^, The current evidence supports an abbreviated period of bed rest for NOM, with markedly shorter periods of hospitalization than the original 2000 APSA guidelines suggested. ^{, , , ,} For example, a 2017 analysis suggested limiting ICU admission to children with elevated SIPA or hematocrit <30% would reduce ICU admissions by two-thirds. Others similarly suggested management strategies for admission and management based on hemodynamics alone—and not injury grade—are safe. ^{, ,} However, one center in the ATOMAC group found that since guideline adoption, they had no statistically significant difference in median length of stay (LOS), regardless of injury grade. Several additional studies have shown an abbreviated period of hospitalization is safe. ^{, , ,} The 2023 APSA guidelines now recommend admission location on clinical condition alone, and not the grade of injury ( Fig. 15.4 ).

ATOMAC guideline v12.0 for management of blunt liver or spleen injury.

CT, computed tomography; Hb, hemoglobin; ICU, intensive care unit; LR, lactated ringers; NOM, nonoperative management; NPO, nothing by mouth; NS, normal saline; PECARN, Pediatric Emergency Care Applied Research Network; PedSRC, Pediatric Surgery Research Consortium; for abdominal CT prediction rules; PRBCs, packed red blood cells; q2h, every 2 hours; q6h, every 6 hours.

Algorithm used by permission of ATOMAC+ Pediatric Trauma Research Network (A+PTRN). CC 4.0 noncommercial attribution. This version used by permission of A+PTRN.

2023 American Pediatric Surgical Association blunt liver/spleen guidelines.

Just as practice management guidelines for ICU or ward admission and length of stay continue to be challenged, so do even the recommendations to admit at all. A 2019 analysis of Washington State Trauma Registry captured 1177 children 16 years or younger with isolated grade I, II, or III SOI, and 3.4% underwent an operation. Interventions did not vary between those who were transferred and those who were not transferred, leading the authors to conclude both that interventions were rare and brought into question the existing transfer policies. A 2020 analysis combined PERCARN and PSRC datasets to evaluate the need for intervention for grade I, II, and III spleen, liver, or kidney injuries. Not a single child with isolated grade I or II injury required intervention. However, the study excluded all children with other injuries, such as bowel perforations. Only three children with grade III injuries had an intervention (each had a transfusion, and one child had an angioembolization); however, the necessity of those interventions was called into question as the patients were hemodynamically normal on initial vital signs and had a hematocrit >28%. Another study of more than 1000 children under 16 years of age in the Trauma Quality Improvement Program database with grade I or II SOI found that only 1.7% underwent an intervention, and the indications were questionable based on review of the data. Together, these data suggest it is reasonable to consider ED discharge for children with isolated grade I or II injuries. The updated ATOMAC guideline, however, puts certain criteria in place to qualify for ED discharge. These include the following: grade 1 or 2 liver or spleen injury, no clinical or radiographic signs of recent or ongoing bleeding, no abdominal wall bruising, no free fluid on CT scan, no concomitant injuries requiring admission, and reliable access to care, transportation, and phone. If a child meets these criteria, then they can reasonably be discharged home if tolerating a diet.

Routine Laboratory and Imaging During Admission

In general, routine repeat imaging and laboratory evaluation during the hospitalization for isolated blunt and/or splenic injury in the absence of hemodynamic changes is not recommended. ^, While initial hemoglobin levels appear to be useful, routine serial hemoglobin rechecks do not appear necessary to identify patients with continued bleeding. A transfusion threshold of 7.0 g/dL for children with blunt trauma has been demonstrated to be safe in multiple studies, including several prospective studies on pediatric trauma patients, as well as a randomized controlled trial of critically ill and injured children in the pediatric ICU. ^{, ,}

Continuous pulse cooximetry has been suggested as a noninvasive method to monitor hemoglobin values and may play a role in inpatient management of SOI. ^, In early studies, cooximetry measurements correlate well with measured hemoglobin concentrations, though differences can result from variations in skin pigmentation, degree of shock, and injury severity.

Discharge Recommendations

Based on multiple prospective studies, ^{, , , ,} stable children who meet specific criteria can be discharged after a brief period of hospitalization, generally after overnight observation. Exceptions include children with multiple intraabdominal organ injuries and those with abdominal wall bruising The 2023 APSA guidelines now recommend discharge based on clinical condition alone, and not the grade of injury ( Fig. 15.4 ). One of the major concerns about NOM of SOI is the risk of delayed bleeding; however, this is quite rare. For example, in splenic injury, the risk of delayed bleeding has been estimated as high as 0.3%, but it is probably less than 0.2% based on clinical experience and the ATOMAC data. Because delayed hemorrhage does occur, appropriate instructions are critical at the time of discharge ( Fig. 15.5 ). After discharge, no imaging is recommended unless children are symptomatic. ^, Overall, there is a lack of data on activity restrictions, but current guidelines recommend grade of injury +2 weeks.

Discharge instructions after blunt liver or spleen injury.

Used by permission of ATOMAC.

Guideline Utilization

Several studies have noted improved resource utilization and higher rates of NOM when management guidelines are utilized. Despite the quantity of literature focused on pediatric SOI and clinical practice guidelines (CPGs), there is notable variability in the quality of the data guiding those CPGs.

Failure of Nonoperative Management

As noted previously, reported failure rates of NOM vary considerably. Several studies have shown hospital type, provider type, presence of a pediatric trauma center within the trauma system, and lack of CPGs may play a role in failure rates. ^{, ,} Patient factors are important in guiding care as well. A multicenter retrospective review described characteristics of children failing NOM, when they fail, and why they fail. Failure was found to be most common in children with the highest grade injuries, with isolated pancreatic injury, and with multiple intraabdominal organ injuries. Failure was infrequent, but when children failed NOM, they tend to do so early, with a median time to failure of 3 hours after arrival. In their retrospective study, 76% of failures occurred by 12 hours. The most common indications for operation were shock or persistent hemorrhage (49%), peritonitis or bowel injury (42%), pancreatic injury (8%), and ruptured diaphragm (1%).

In 2017, the ATOMAC+ group published a prospective study of 1008 children with liver and/or spleen injuries. Seven percent of patients who were candidates for initial NOM required laparotomy or laparoscopy, but only 3% with attempted NOM required operation for bleeding. Operations for reasons other than bleeding included 21 intestinal injuries; 15 hematoma evacuations, washouts, or drain placements; nine pancreatic injuries; five mesenteric injuries; three diaphragm injuries; and two bladder injuries. Patients who failed were more likely to undergo early blood transfusion, within 2.3 hours of injury. The median time to failure for any reason was 5.0 (interquartile range, 3.0–21.0) hours after injury and 3.2 (interquartile range, 2.0–5.0) hours for hemorrhage. In yet another study, interventions for SOI, including seven angioembolic procedures, occurred within 8 hours of arrival, and many patients had hypotension and received a transfusion. While contrast extravasation has often been thought to be a risk factor for failure of NOM, ^, other studies have brought this into question. In a study of 318 patients with splenic or liver injury, 30 (9%) had contrast extravasation (i.e., blush) on CT. Overall, contrast extravasation was associated with higher injury grade, higher Injury Severity Score (ISS), and higher ICU utilization and blood product transfusion. Only 17% of patients (5 of 30 patients) with isolated splenic or hepatic blush on CT required definitive interventions (one embolization, three splenectomies, and one liver packing). The other 83% of patients with blush were successfully managed nonoperatively. In this study, the primary indication for intervention was hemodynamic instability, continuing need for transfusion of blood products (i.e., greater than 40 mL/kg), or findings of bowel perforation on radiologic imaging.

As important as predictors of failure of NOM are predictors of successful NOM. Subsequent publications from the ATOMAC group found that a negative FAST at initial assessment was predictive of successful NOM.

A 2020 analysis using deep learning assessed clinical values, laboratory results, and imaging findings in the first 4 hours of admission to predict the need for massive transfusion, failure of NOM, mortality, and successful NOM without intervention. Interestingly, most of these clinical characteristics had a low correlation with failure of NOM. Factors with the highest absolute correlation with failure of NOM were abnormal thromboelastogram (TEG) [Q14]values, specifically LY30 (lysis at 30 minutes) ( r = 0.43), R (time to start forming clot) ( r = 0.40), and MA (maximum amplitude) ( r = 0.38). FAST had a weak correlation with failure of NOM ( r = 0.15). Grade of organ injury (liver, spleen, and/or kidney) also had weak correlation with failure of NOM (R < 0.2 in all).

Defining the Need for Operation

For several years, consensus evidence has suggested 40 mL/kg of blood products during the first 24 hours is a breakpoint at which NOM is less likely to be successful. ^, Recent pediatric data from the United States military have confirmed 40 mL/kg is a predictor of early and late mortality in children. Additionally, the need for early transfusion, systolic blood pressure less than 50 mmHg, or a recurrent episode of hypotension suggest a higher risk of mortality. ^{, ,} Early recurrent hypotension after blood transfusion in a pediatric trauma patient believed to be bleeding from an SOI indicates failure of NOM and requires operation or other interventions such as embolization. ^,

Operative Management of Liver/Spleen Bleeding

For splenic hemorrhage, the abdomen is initially packed in all four quadrants. Packs are removed from one quadrant at a time, typically leaving the quadrant(s) most likely to contain the source of bleeding until last. Definitive treatment options for splenic bleeding include packing and waiting, angiography with packing in place, splenorrhaphy, or splenectomy. As NOM has become more successful, fewer than 400 children per year in the US undergo splenectomy for trauma.

Operative management of liver bleeding can be challenging. The Western Trauma Association guideline for operative management of adult blunt hepatic trauma is useful ( Fig. 15.6 ). In this stepwise approach, the abdomen is packed. If the bleeding stops, the patient goes for angiography and ICU monitoring. If packing fails to stop the hemorrhage, a Pringle maneuver is performed. If this controls bleeding, the bleeding is most likely from a hepatic artery or a portal vein branch. These are treated with selective vessel ligation and omental packing. However, if the bleeding continues, the patient most likely has an inferior vena cava (IVC) injury, and vascular isolation will be necessary for control. A median sternotomy may be needed, and the IVC injury is approached after vascular isolation. This is demonstrated in a recently published video.

Western Trauma Association guideline for operative management.

SHAL, Selective Hepatic Artery Ligation.

http://westerntrauma.org/algorithms/OperativeManagementOfAdultBluntHepaticTraumaNotes/NoteG.html .

Angioembolization

Successful control of bleeding with angioembolization for children and adolescents with SOI has been reported in several series and is included in the algorithmic management of traumatic injuries in children. Contrast extravasation is seen in approximately 5%–15% of children with splenic injury. ^, The majority of children with contrast extravasation do not need angioembolization, and the current role for it appears to be limited to children who are otherwise failing NOM. ^{, ,} In cases of hemobilia (upper gastrointestinal bleeding due to liver injury with bleeding into the bile ducts), angioembolization has been described with good success. Use of angioembolization in managing pseudoaneurysms of the liver or spleen is controversial and probably not necessary in most splenic pseudoaneurysms. ^,

ERCP

Endoscopic retrograde cholangio-pancreaticography (ERCP) after liver trauma appears to have a role in identifying and treating children with major bile duct injuries ( Fig. 15.7 ). ^, Stenting across the injured duct may be possible in selective cases. ^, Additionally, other therapeutic interventions include sphincterotomy and stenting of the ampulla to decrease the biliary tract pressure, even if the injury itself cannot be stented. These procedures are often done as an adjunct to percutaneous drainage of a biloma secondary to a traumatic bile duct injury.

ERCP showing major bile duct injury.

Endoscopic retrograde cholangiopancreatography shows a leak from the confluence of the right and left hepatic ducts. Note the leakage of contrast pooling under the liver.

Renal injuries are less common than injuries to the liver or spleen, representing only about one-third as many admissions. The initial management of blunt renal injury is similar to management of liver and spleen injuries, with >97% of cases managed nonoperatively. ^{, ,} One exception is that bed rest after blunt renal injury is not required. Omission of mandatory bed rest for stable patients with blunt renal injury appears to result in a shortened hospitalization without an increased risk of bleeding or readmission.

While NOM of renal injury grades I through III has been well accepted for many years, management of high-grade injuries without operation is now also the norm. In one series reporting operative intervention in children with low-grade renal injuries, the reason for operation was generally for management of other injuries or for children found to have underlying congenital renal anomalies. For grade IV and V renal injuries, surgeons have adopted NOM for hemodynamically stable patients with successful outcomes. In a meta-analysis assessing NOM in grade IV renal injuries, 73% of patients were managed with NOM without intervention. At least partial renal preservation was possible in 95% of the cases. Successful NOM for grade IV and V renal injuries has been reported in 80%–100% of cases.

Risk factors for failure of NOM include injuries involving the renal collecting system, large perinephric hematomas, urinomas greater than 4 cm, lacerations to the antero-medial or medial portion of the kidney, the presence of dissociated renal fragments, and interpolar extravasation. Transcatheter arterial embolization has been advocated as a first step in the management of active renal bleeding in order to maximally preserve renal parenchyma and function. The primary indication for operative management is persistent hemodynamic instability. Adjunctive procedures such as stenting, percutaneous drainage, and angioembolization may assist in avoiding laparotomy. ^, Late hypertension is uncommon but occurs transiently in 6% of high-grade (grade III or above) injuries. A small number of these patients require long-term antihypertensive treatment. There is currently a large multiinstitutional study underway through the American Association for the Surgery of Trauma (AAST), called the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), which is studying initial evaluation, management, interventions, and follow-up for children with isolated renal injury. The first publication from this work included a review of data from 13 participating level I trauma centers from 2010 to 2019, and it reported on 1216 pediatric patients with renal injury. Of those, 29.3% were isolated renal injuries, and 65.6% were grade III–V injuries. The majority (86.4%) of renal injuries were managed nonoperatively, and 0.9% had angioembolization. The rate of avoidable transfer, defined as a patient transferred from another facility and then discharged within 2 days without intervention or advanced imaging, was 28.2%. The Mi-PARTS authors aim to next answer specific questions related to imaging, bleeding risk, and management of collecting system injury among others.

Pancreatic injuries in children are relatively uncommon compared with other abdominal injuries, with many major pediatric trauma centers managing less than one high-grade pancreatic injury per year. ^, The AAST pancreatic injury grade is a potentially useful guide for management decisions, but time from injury to diagnosis is also important in determining the optimal management ( Table 15.2 ). The most important aspects of grading pancreatic injuries are the location of the injury and the status of the main pancreatic duct. ^,

Management of children with a high-grade pancreatic injury is controversial. ^{, , ,} AAST grade I and II pancreatic injuries are best managed nonoperatively. Patients with a transected main pancreatic duct (grade III) have fewer complications with distal pancreatectomy, and laparoscopic distal pancreatectomy after trauma has also been found to be beneficial, if diagnosed shortly after the injury. ^{, ,} The 2014 multiinstitutional retrospective study done by the Pancreatic Trauma in Children Study Group found fewer complications, fewer pseudocysts, less time on parenteral nutrition, fewer interventions, and a shorter hospital length of stay with an operative approach. On the other hand, there are studies that have shown successful NOM for ductal injuries. ^{, , ,} In a recent multicenter study of 86 high-grade pancreatic injuries (grades III–V), NOM was attempted in all patients, though ultimately 6 (7%) needed a laparotomy for other indications or “exploration of pancreatic injury without pancreatic transection.” MRCP was only completed in 29% of patients and ERCP in 24%, suggesting a lack of clarity on degree of ductal injury.

In contrast to NOM for splenic injury, NOM of pancreatic injury does not always preserve pancreatic parenchyma. Studies have shown that unoperated pancreatic duct injury results in loss of the pancreas distal to the ductal injury, likely due to pancreatic enzyme leak ( Fig. 15.8 ). ^, Injuries involving less than 50% of the pancreas do not appear to result in endocrine or exocrine dysfunction. However, those patients who lose more than 50% of pancreatic function may have abnormal glucose tolerance. For proximal injuries, operative reconstruction of the distal pancreas with a Roux-en-Y pancreaticojejunostomy provides ductal drainage to the gastrointestinal tract, allowing pancreatic salvage and preserving both endocrine and exocrine function. ^, A simpler reconstruction with a pancreaticogastrostomy has also been described, and large adult series now show good outcomes with elective central pancreatectomy for both traumatic and nontraumatic disease. ^{, ,}

CT scan showing typical atrophy of the pancreas distal to the site of main pancreatic duct injury.

(A) Example of transected pancreas ( arrow ). Note associated duodenal hematoma ( arrowhead ). (B) Pancreatic head visualized, but body and tail to left of superior mesenteric vessels have atrophied completely.

From Wales PW, Shuckett B, Kim PCW. Long-term outcome after nonoperative management of complete traumatic pancreatic transection in children. J Pediat Surg . 2001;36(5):823–827.

Successful endoscopic management of a pancreatic injury has also been reported and may have advantages in injuries to the pancreatic head. ^{, ,} Failures are not uncommon, and pancreatic preservation does not appear to be likely if the duct is completely transected. The ideal use of endoscopy appears to be for injuries where the pancreatic stent can completely cross the injured duct, rather than cases treated with sphincterotomy and stenting of the ampulla.

Blunt trauma results in intestinal injuries in a significant number of children. Motorized vehicles and handlebar injuries are the most common mechanism of blunt intestinal injury in older children, but nonaccidental trauma is also a major contributor in young children. ^{, ,} The most common blunt intestinal injures are those at or near areas fixed to the retroperitoneum, such as the duodenum, proximal jejunum, sigmoid colon, and rectum. These fixed areas are less mobile and are therefore less able to move away from an abdominal impact. In addition to a direct impact injury, the bowel may sustain mesenteric injury with resultant ischemia. Additionally, certain nonabdominal injuries are associated with hollow viscous injury. For example, Chance fractures, fractures of all three spinal columns associated with flexion/distraction of the spine that occurs with rapid deceleration against a fixed point, are associated with hollow viscous injury regardless of mechanism of injury, and the association is more common in children than in adults (51.3% vs. 8.4%, respectively).

The most common surgical indication in blunt abdominal trauma is a hollow viscus injury, and concern for missing blunt intestinal injury was an initial reason for slow adoption of NOM for abdominal trauma. In 2010, the APSA Trauma Committee published one of the few large studies of blunt intestinal injury, which demonstrated that a moderate delay in diagnosis, even beyond 24 hours, did not negatively impact outcome. In a recent ATOMAC study, 2% of children with SOI were ultimately found to have an intestinal injury requiring operation, and an additional 0.5% had mesenteric injuries that led to exploration. As was seen in the APSA study, delays in diagnosis and operation were not uncommon, but these delays did not impact mortality.

Duodenal Injuries

Duodenal injuries are relatively infrequent but can be difficult to manage and associated with significant morbidity. In children less than 4 years of age, this injury is strongly associated with child abuse ( Fig. 15.9 ). ^, Blunt force trauma to the abdomen by the assailant often injures the relatively fixed second portion of the duodenum, although other areas may be damaged. In older children, a duodenal injury is typically caused by a concentrated transfer of injury to the duodenum, often where it crosses the spine. Motor vehicle collision is the most common mechanism after child abuse.

Duodenal injury associated with nonaccidental trauma and delayed presentation. This patient also had localized mesenteric bruising confirming blunt force trauma.

AAST duodenal injury grades are shown ( Table 15.3 ). Patients with an intramural duodenal hematoma can often be managed with nutritional support with a reasonable expectation of resolution of the hematoma at a median of 9 days. In cases of duodenal perforation, operative intervention is needed, even when diagnosed late. For nondestructive injuries, primary repair of the duodenum with or without a drain is reasonable. Additional management options may include pyloric exclusion, diversion and drainage, or reconstruction pending patient condition.

Table 15.3

AAST Duodenal Injury Grade.

From Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Shackford SR, Champion HR, et al. Organ Injury Scaling. Surg Clin N Am . 1995;75(2):293–303.

Grade a	Type of injury	Description of Injury	ICD-9	AIS-90
I	Hematoma	Involving single portion of duodenum	863.21	2
	Laceration	Partial thickness, no perforation	863.21	3
II	Hematoma	Involving more than one portion	863.21	2
	Laceration	Disruption <50% of circumference	863.31	4
III	Laceration	Disruption 50%–75% of circumference of D2	863.31	4
		Disruption 50%–100% of circumference of D1, D3, D4	863.31	4
IV	Laceration	Disruption >75% of circumference of D2	863.31	5
		Involving ampulla or distal common bile duct		5
V	Laceration	Massive disruption of duodenopancreatic complex	863.31	5
	Vascular	Devascularization of duodenum	863.31	5

D1, First position of duodenum; D2, second portion of duodenum; D3, third portion of duodenum; D4, fourth portion of duodenum.

Small Bowel Injuries

Injuries to the small intestine are generally repaired primarily in penetrating trauma but may require resection and anastomosis following blunt injury or cases where the mesentery has been torn ( Fig. 15.10 ). In rare cases of avulsion of the superior mesenteric artery, urgent vascular reconstruction based on training and available resources may be successful, but these injuries are often lethal. ^,

Laparoscopy showing blunt intestinal injury.

Courtesy J.W. Eubanks III.

Rectal Injury

A rectal injury may occur through a variety of mechanisms including sexual abuse, straddle injuries, watercraft injury, and accidental impalement. Personal watercraft injuries (e.g., jet skis) may cause hydrostatic injury as the propulsive force enters the rectum, causing perforation. ^, Rarely, pelvic fractures may secondarily perforate the rectum. Rectal examination alone is unreliable to exclude these injuries. Abdominopelvic CT with or without anoscopy, proctoscopy, vaginoscopy, or cystoscopy may be helpful.

Rectal injuries above the peritoneal reflection are treated in the same manner as colonic injuries, and repair without diversion is reasonable. Below the peritoneal reflection, management depends on the degree of injury and concurrent injuries. The Eastern Association for the Surgery of Trauma guidelines conditionally recommend diversion, as do some pediatric surgeons. However, the data are limited. For injuries less than 50% of the bowel circumference, primary transanal repair may be possible without diversion. In cases with greater than 50% of the circumference involved, or significant destruction of the surrounding tissues, primary repair and diversion is advocated. Females with combined rectal (above the dentate line) and vaginal injuries have a high risk of developing a rectovaginal fistula regardless of management, but early diversion may help with definitive repair of future fistulas ( Fig. 15.11 ). Most cases with uncomplicated isolated rectal injuries undergoing early repair retain fecal continence.

Vaginoscopy demonstrating rectovaginal fistula after perforating rectal trauma.

The rectovaginal fistula developed despite proximal diversion and immediate repair. Cervix is visible in the background, and the most proximal posterior vaginal wall is elevated. The deep red rectal mucosa has fistulized to the lighter pink proximal vagina.

Blunt abdominal aortic injury in a child is an uncommon event. It is often due to severe deceleration injuries. Patterns of injury associated with blunt abdominal aortic injury can include lap belt bruising, disruption of the abdominal wall fascia, Chance fractures of the lumbar spine, bowel injury, and/or disruption of the cauda equina. ^, The Western Trauma Association Multi-Center Trials conducted the largest study to date, which included 113 patients from 12 major trauma centers. The median age in the study was 38 years, with a range between 6 and 88 years. There was a wide range of severity, and NOM is successful in uncomplicated cases without external aortic contour abnormality on CT.

Endovascular management and stenting of the aorta and iliac vessels in children have been reported, but primary repair of the aortic injury is still performed in many centers due both to limited expertise and the size of the devices relative to small children. ^{, ,} The primary advantages of endovascular stenting include potentially avoiding a laparotomy or avoiding contamination of the vascular repair in patients with a concurrent bowel injury. A retrospective review of 16 pediatric patients with blunt abdominal injury described initial management, associated injuries, and outcomes. The authors highlight the importance of transfer to a facility with vascular expertise and note that “delayed” aortic intervention is safe as long as there is preserved perfusion to the lower extremities. Of the 16 patients, nine (56%) required aortic repair. Among the remaining, six patients (38%) had delayed repair, with a median interval to repair of 52 days (range, 2–916 days). One-half of the delayed repairs were performed during the index hospitalization. The study supports the need for more structured surveillance strategy. At this point, long-term follow-up studies in children are not available.

Rupture of the diaphragm due to blunt trauma occurs infrequently but is typically associated with a severe and rapid increase in intraabdominal pressure. ^, It is frequently diagnosed late, and even delayed presentations are not uncommon. Repair may be done at laparotomy for other injuries, but a primary laparoscopic and thoracoscopic repair are both feasible. ^, Thoracoscopic repair may have advantages in children with delayed presentations, including better access to adhesions that have developed in the chest and a better view of the diaphragm. The abdominal approach is preferred in the acute setting to exclude associated intraabdominal injury.

Late abdominal pain after NOM of blunt splenic injury is common and was seen in up to 15% of patients in one study. When reimaging for pain is performed, most studies show only a healing spleen. Pseudocysts and pseudoaneurysms are occasionally identified ( Fig. 15.12 ).

Laparoscopy showing splenic pseudocyst.

Splenic Pseudoaneurysm

Splenic pseudoaneurysms are vascular complications that result from injury to the vessel wall ( Fig. 15.13 ). In contrast to a true aneurysmal dilation, all layers of the vessel wall are not involved in the dilated pseudoaneurysm. An injury to the vessel is typically contained by the surrounding tissue, which compresses the associated parenchyma. Recent studies have found that splenic pseudoaneurysms after blunt trauma are common, with as many as 17% of patients developing a pseudoaneurysm. The clinical significance of this finding has been challenged. No clinically significant vascular complications were found in long-term follow-up of a large series of patients with splenic injury. Over an 18-year series, 10 pseudoaneurysms were found among 362 children with splenic injuries. These were more common following high-grade traumatic injuries, and spontaneous thrombosis was common. Two were electively embolized, and one splenic artery pseudoaneurysm bled. Routine or increased use of reimaging is associated with higher rates of identification, often without clinical significance. ^, In another study identifying asymptomatic splenic artery pseudoaneurysms, 89% underwent spontaneous thrombosis ( Fig. 15.14 ). The APSA guidelines do not recommend routine reimaging, and there is no strong evidence for routine reimaging after splenic trauma. For symptomatic pseudoaneurysms, angioembolization may be beneficial, as it was shown to be successful in over 85% of cases in one study.

Computed tomography showing splenic pseudoaneurysm.

Panel A shows the initial splenic injury. The patient was having intermittent right upper-quadrant abdominal pain. Postinjury imaging at 6 weeks shows an unusually large splenic pseudoaneurysm, which was embolized prophylactically.

From Yardeni D, Polley TZ, Jr., Coran AG. Splenic artery embolization for post-traumatic splenic artery pseudoaneurysm in children. J Trauma. 2004;57(2):404–407.

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