In the trauma patient, the mechanism of injury is sought to help drive the diagnosis and evaluation. Healthcare facilities often have protocols for these evaluations. Being familiar with these protocols optimizes information gathering and subsequent treatment and disposition decisions.
Radiological Examination Recommendations
Recommendations for a child/adolescent with a suspicion of significant trauma:
Cervical spine imaging
The patient should remain in c-spine immobilization until the cervical spine has been appropriately cleared. Imaging of the remainder of the spine is determined by the index of suspicion, mechanism of injury, and results of the initial examination.
MRI
When imaging the spine, if there is a strong suspicion of cord involvement, an MRI may be considered.
CT scan of the head
A CT scan of the head should be ordered for any significant change in mental status as determined by the physical examination or the history.
CT imaging of chest and/or abdomen-pelvis
These scans should be ordered for a child/adolescent with a history of significant trauma or physical findings consistent with potential injuries to those areas.
Plain films
Extremity films are usually ordered based on physical examination findings, namely pain or abnormal structural/functional findings.
Head Trauma
Intracranial manifestations of trauma are seen with inflicted head trauma or significant accidental injury, such as motor vehicle crashes, and may lead to significant morbidity or mortality in infants. In child abuse cases, these injuries often present with minimal or no external signs of trauma.
Intracranial manifestations of trauma:
Parenchymal injury
Swelling, infarction, hypoxia/ischemia, or axonal injury. Occurs with direct head trauma (contusions) or with severe shaking and/or impact. These injuries lead to the greatest morbidity and mortality. Note that if a contusion is identified, a repeat imaging study is recommended after the first 24-48 hours because these lesions often increase in size and cause delayed neurological consequences. Traumatic axonal injury results from extremely severe head trauma and is generally identified only at autopsy. This type of injury leads to severe, permanent brain injury.
Subdural hemorrhages
Classic intracranial injury finding from abuse, especially shaken babies. Occurs when rotational forces cause tearing of bridging arteries or veins with bleeding into the subdural area. Sutures do not confine the crescent appearing bleed that has a concave margin against the surface of the brain. These hemorrhages can extend along the full surface of the cerebral hemisphere. The posterior interhemispheric fissure is the classic location for inflicted head trauma.
Subarachnoid hemorrhages
A common finding in inflicted head injury. This space lies adjacent to the brain and extends into the cortical sulci.
Epidural hemorrhages
Seen commonly with accidental injury from translational forces. These hemorrhages are not usually the result of child abuse.
Follow-up imaging in child abuse is often necessary in order to identify parenchymal volume loss, chronic subdural hematomas or collections, and communicating hydrocephalus. Rebleeding into long-term collections may occur with minimal trauma but generally does not result in acute deterioration of mental/neurologic status, parenchymal injury, or acute subarachnoid bleeding.
Macrocephaly as a result of long-term subdurals has been described. A missed case of a mild subdural could later present as a child with an enlarging head circumference or communicating hydrocephalus. A skeletal survey should be considered in order to rule out other trauma.
Microcephaly may occur if head trauma results in parenchymal damage and subsequent volume loss and lack of brain growth.
