Michael L. Nance

Optimal Restraint Reduces the Risk of Abdominal Injury in Children Involved in Motor Vehicle Crashes

Background:The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated. Methods:Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10,927 crashes involving 17,132 restrained children, representing 210,926 children in 136,734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale ≥2 severity. Results:Among all restrained children, optimal was noted in 59% (n = 120,473) and suboptimal in 41% (n = 83,555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87–6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds. Conclusions:Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.

The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures.

BACKGROUNDnComputed tomographic (CT) scanning is sensitive in detecting pelvic fractures in the pediatric patient. Pelvic fractures in the pediatric population rarely require emergent intervention, thus providing time to obtain the optimal imaging study. The objective of this study was to compare pelvic radiographs and abdominal pelvic CT scans of all pediatric trauma patients with pelvic injury to determine the role of pelvic imaging in the immediate trauma resuscitation.nnnMETHODSnA retrospective review was performed of pediatric patients (age < 18 years) with a pelvic fracture identified from the registry of a Level I pediatric trauma center for the period 1993 to 2001. Patients with a documented pelvic injury and both a pelvic CT scan and pelvic radiograph available for review were extracted for analysis. For this study, all films were re-reviewed by an attending pediatric radiologist, and the abnormalities were categorized by the area of injury. The data were comparatively analyzed according to the area of injury and the soft tissue findings.nnnRESULTSnFor the 8-year period, 130 pediatric patients with a pelvic fracture were identified, including 103 patients with both a pelvic CT scan and radiographs. Of the 151 fractures identified by pelvic CT scan, 81 were also identified by the pelvic radiograph (54%). There were 38 soft tissue hematomas noted by pelvic CT scan and only 2 identified by the pelvic radiograph. The greatest discrepancy was noted in comparison of the sacral region (16 abnormal pelvic CT scans vs. 3 abnormal radiographs); the least discrepancy was noted in the evaluation of the hip (6 abnormal pelvic CT scans vs. 5 abnormal radiographs).nnnCONCLUSIONnThe pelvic radiograph lacked the sensitivity of the pelvic CT scan for detecting pelvic fractures in all anatomic areas evaluated. Pelvic CT scan also offers additional information regarding soft tissue injury not available on most pelvic radiographs. In the trauma patient that will undergo abdominopelvic CT scanning as part of the trauma evaluation, a pelvic radiograph may be superfluous. Screening pelvic radiography should be reserved for the rare unstable patient or the patient in whom an abdominopelvic CT scan is not otherwise indicated.

Skateboard-associated injuries: participation-based estimates and injury characteristics.

BACKGROUNDnSkateboarding is a popular recreational activity but has attendant associated risks. To place this risk in perspective, participation-based rates of injury were determined and compared with those of other selected sports. Skateboard-associated injuries were evaluated over time to determine participation-based trends in injury prevalence.nnnMETHODSnRates of skateboard-associated injury were studied for the 12-year period 1987 to 1998 for participants aged 7 years or older. The National Electronic Injury Surveillance System provided injury estimates for skateboarding and the selected additional sporting activities. The National Sporting Goods Association annual survey of nationally representative households provided participation estimates. A participation-based rate of injury was calculated from these data sets for the selected sports for the year 1998.nnnRESULTSnThe 1998 rate of emergency department-treated skateboard-associated injuries-8.9 injuries per 1,000 participants (95% confidence interval [CI], 6.2, 11.6)-was twice as high as in-line skating (3.9 [95% CI, 3.1, 4.8]) and half as high as basketball (21.2 [95% CI, 18.3, 24.1]). The rate of skateboard-associated injuries declined from 1987 to 1993 but is again increasing: the 1998 rate was twice that of 1993 (4.5 [95% CI, 1.6, 7.4] and 8.9 [95% CI, 6.2, 11.6], respectively). Increases occurred primarily among adolescent and young adult skateboarders. The most frequent injuries in 1998 were ankle strain/sprain and wrist fracture: 1.2 (95% CI, 0.8, 1.6) and 0.6 (95% CI, 0.4, 0.8) per 1,000, respectively. Skateboard-associated injuries requiring hospitalization occurred in 2.9% and were 11.4 (95% CI, 7.5, 17.5) times more likely to have occurred as a result of a crash with a motor vehicle than injuries in those patients not hospitalized.nnnCONCLUSIONnThis study is the first to relate skateboarding and other sport injuries to participation exposures. We found that skateboarding is a comparatively safe sport; however, increased rates of injury are occurring in adolescent and young adult skateboarders. The most common injuries are musculoskeletal; the more serious injuries resulting in hospitalization typically involve a crash with a motor vehicle. This new methodology that uses participation-based injury rates might contribute to more effective injury control initiatives.

Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes.

BACKGROUNDnBoth solid and hollow visceral abdominal injuries have been associated with the use of seat belts in children involved in motor vehicle crashes. The relationship between the types of restraint used and the pattern of abdominal injury is unknown.nnnMETHODSnA probability sample of restrained children involved in crashes was enrolled in an ongoing crash surveillance system (1998 through 2002) linking insurance claims data to telephone survey and crash investigation data. Significant abdominal injuries were considered when the Abbreviated Injury Scale (AIS) score was > or =2 and were defined as hollow visceral (HV; intestine, bladder), or solid visceral (liver, spleen, pancreas, kidney). Restraint type was categorized as optimal restraint (OR) or suboptimal restraint (S-OR) based on the childs age and size.nnnRESULTSnFor the 33 months of review, interviews were obtained for 13,558 restrained children aged 0 to 15 years, of which, 56% were OR (n = 7,591) and 44% were S-OR (n = 5,967). A significant abdominal injury was recorded in 78 children. A hollow visceral injury was recorded in 38 (9 OR and 29 S-OR), and a solid visceral injury in 32 (18 OR and 14 S-OR). Both hollow and solid visceral injuries were present in 8 children (2 OR and 6 S-OR). Suboptimally restrained children had a higher risk for hollow visceral injury when compared with optimally restrained children (Odds Ratio, 4.14 [95% Confidence Interval 1.33 to 13.22, P <.01]).nnnCONCLUSIONSnAmong restrained children with intraabdominal injuries, those who were suboptimally restrained were 4 times more likely to have a hollow visceral than a solid visceral injury when compared with those who were optimally restrained. This suggests that the mechanism of injury for hollow viscus may be directly related to the improper positioning of the restraint.

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

Nonintracranial fatal firearm injuries in children: Implications for treatment

BACKGROUNDnUnderstanding the injury characteristics of nonintracranial fatal (NIF) gunshot wounds in children treated in a statewide trauma system will help guide effective treatment strategies.nnnMETHODSnThis study was a retrospective analysis of children fatally injured with firearms. The review included demographic information, firearm injury characteristics, and outcome. The setting included trauma centers participating in a statewide trauma registry. Patients were all children (age < 18 years) treated in trauma centers for NIF gunshot wounds from January 1988 through December 2000. The main outcome measures were characteristics of fatal firearm injuries in children.nnnRESULTSnOver the 13-year period, there were 1,954 children with firearm injuries including 368 (18.8%) children with fatal wounds. Of the fatally wounded children, 177 (48.1%) had no intracranial injury. The NIF injury population was 90.4% male, with a mean age of 14.9 years (range, <1-17 years) and an Injury Severity Score of 38.2 (range, 9-75). Over 95% of deaths in this group occurred within 24 hours of admission. Although injuries to the thorax were most common (78.5%), 48.6% of the NIF cohort had injuries to multiple body regions, including 31% with injuries in both the abdomen and thorax. Compared with all children wounded by firearms, NIF firearm injury patients had, on average, more body regions injured (1.6 vs. 1.1, p < 0.001) and a greater total number of injuries (6.0 vs. 3.5, p < 0.001). Patients with an NIF injury were more likely to suffer a major vascular injury (54.8% vs. 13.8%, p < 0.001), lung injury (56.5% vs. 12.9%, p < 0.001), or cardiac injury (44.6% vs. 4.6%, p < 0.001) than all children with a firearm injury.nnnCONCLUSIONnMost children who arrive at trauma centers alive and subsequently die from NIF firearm injuries do so rapidly from major vascular and thoracic injury. Almost half of these children have injuries to multiple body regions, further complicating management. Innovative, aggressive treatment approaches should be sought to improve survival in this extremely injured cohort of children.