Trauma is the leading cause of death in the pediatric population and is among the most common reasons for ED visits by children. Imaging is an important tool for the diagnosis and management of pediatric trauma, but there are risks associated with exposure to ionizing radiation. In pediatric head and neck injuries, clinical findings and clinical decision tools can help inform selection of the most appropriate imaging modalities for the trauma patient, while also reducing unnecessary radiation exposure. This supplement reviews evidence-based recommendations for imaging decisions and interpretations in skull fractures, traumatic brain injuries, abusive head trauma, cervical spine injuries, and facial bone fractures. Examples demonstrating imaging modalities and specific findings for the types of injuries are also provided.
Trauma is the leading cause of pediatric mortality and long-term disability in the United States; each year, nearly 8 million children are treated for injuries, resulting in approximately 8000 deaths and an annual financial impact estimated at >$50 billion.1 Studies have demonstrated improved outcomes at pediatric centers or trauma programs that have fully integrated pediatric and trauma services; however, approximately 17 million children in the United States do not live within an hour of a pediatric trauma center.1 Ultimately, the best approach to addressing the mortality and disability associated with pediatric trauma is injury prevention. Programs such as Safe Kids Worldwide® educate parents, institutions, and clinicians about child safety, and provide resources on injury prevention. These programs play an important role in decreasing pediatric mortality from injury1 and should be incorporated in all trauma programs.
Imaging remains a critical tool in the evaluation of pediatric trauma patients. The evaluation of a child with head and/or neck injuries involves consideration of the anatomic and biomechanical differences between children and adults, as well as assessment of the risks associated with exposure to ionizing radiation in pediatric patients. The use of clinical decision tools can help reduce unnecessary imaging in head injuries. In all types of pediatric head and neck injuries, the mechanism of injury and the clinical findings will inform imaging decisions. This supplement provides evidence-based recommendations for the selection of appropriate diagnostic imaging modalities for pediatric patients with skull fractures, traumatic brain injuries, abusive head trauma, cervical spine injuries, and facial bone fractures. Recommendations for management of these injuries are not included in the scope of this supplement.
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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
6. * Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo). 2017;57(2):82-93. (Review) DOI: 10.2176/nmc.ra.2016-0191
7. * Gunda D, Cornwell BO, Dahmoush HM, et al. Pediatric central nervous system imaging of nonaccidental trauma: beyond subdural hematomas. Radiographics. 2019;39(1):213-228. (Review) DOI: 10.1148/rg.2019180084
10. * Sarkar K, Keachie K, Nguyen U, et al. Computed tomography characteristics in pediatric versus adult traumatic brain injury. J Neurosurg Pediatr. 2014;13(3):307-314. (Retrospective review; 1206 patients) DOI: 10.3171/2013.12.PEDS13223
16. United States Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. Child maltreatment 2019. Accessed August 15, 2021. (Government report)
17. United States Centers for Disease Control and Prevention. Preventing child abuse & neglect. Accessed August 15, 2021. (Informational website)
19. * Lustrin ES, Karakas SP, Ortiz AO, et al. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics. 2003;23(3):539-560. (Review) DOI: 10.1148/rg.233025121
20. * McAllister AS, Nagaraj U, Radhakrishnan R. Emergent imaging of pediatric cervical spine trauma. Radiographics. 2019;39(4):1126-1142. (Review) DOI: 10.1148/rg.2019180100
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Keywords: pediatric trauma, imaging, trauma imaging, head trauma, neck trauma, CT, computed tomography, MRI, magnetic resonance imaging, PECARN, skull fracture, scalp hematoma, epidural hematoma, subdural hematoma, traumatic brain injury, TBI, ciTBI, subarachnoid hemorrhage, pseudosubarachnoid hemorrhage, parenchymal contusion, diffuse axonal injury, DAI, abusive head trauma, AHT, nonaccidental trauma, NAT, cervical spine injury, pseudosubluxation, ring apophyses, Swischuk line, facial bone fracture, mandibular fracture, maxillary fracture
Jinel Scott, MD, MBA; Tarundeep Grewal, MD; Selwena Brewster, MD; Ambreen Khan, MD, FAAP
Michelle Arzubi-Hughes, DO; Peter Gutierrez, MD, FAAP
August 15, 2021