Optimizing Imaging in the Pediatric Trauma Patient, Part 1: Head and Neck Trauma - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

Imaging is often critical to the diagnosis and management of head and neck trauma in pediatric patients. Clinicians must balance the need to reduce unnecessary radiation exposure in these patients with the need to quickly identify serious and potentially life-threatening injuries. Consideration of the mechanism of injury and the clinical findings are required to make appropriate imaging decisions. This supplement reviews evidence-based recommendations for imaging decisions and interpretations in pediatric patients with head and neck injuries, and provides examples of imaging modalities and findings. You will learn:

The role of clinical decision rules in imaging of pediatric head injuries

Why CT is generally the preferred imaging modality for detecting skull fractures in children

How skull fractures can be distinguished from skull sutures on CT imaging

Potential complications of skull fractures that are unique to pediatric patients and are detectable on imaging

Which clinical findings support the use of MRI in patients with traumatic brain injuries

How to interpret imaging for indications of intracranial injuries such as epidural hematoma, subdural hematoma, subarachnoid hemorrhage, parenchymal contusion, and diffuse axonal injury

When radiologic screening for abusive head trauma is warranted in pediatric patients

How to recognize normal anatomic variants in children that may be mistaken for pathology on cervical spine imaging

When either CT or MRI is indicated in children with cervical spine injuries

Why CT is the imaging modality of choice for diagnosing facial bone fractures in pediatric patients

1. About This Issue
2. Abstract
3. Introduction
4. Radiation Reduction
   1. Clinical Decision Rules for Pediatric Head Injury
5. Skull Fractures
   1. Imaging Modalities in Skull Fractures
6. Traumatic Brain Injuries
   1. Imaging Modalities in Traumatic Brain Injuries
      1. Computed Tomography
      2. Magnetic Resonance Imaging
      3. Epidural Hematoma
      4. Subdural Hematoma
      5. Subarachnoid Hemorrhage
      6. Parenchymal Contusions
      7. Diffuse Axonal Injury
7. Abusive Head Trauma
   1. Imaging in Abusive Head Trauma
8. Cervical Spine Injuries
   1. Imaging Modalities in Cervical Spine Injuries
      1. Radiography
      2. Computed Tomography
      3. Magnetic Resonance Imaging
9. Facial Bone Fractures
   1. Imaging Modalities in Facial Bone Fractures
      1. Radiography
      2. Computed Tomography
10. Summary
11. Figures
    1. Figure 1. PECARN Decision Rule for Patients Aged <2 Years
    2. Figure 2. PECARN Decision Rule for Patients Aged 2 to 18 Years
    3. Figure 3. Minimally Depressed Skull Fracture and Scalp Hematoma on Head CT
    4. Figure 4. Nondisplaced Skull Fracture and Scalp Hematoma on Head CT
    5. Figure 5. Depressed Skull Fracture on Head CT
    6. Figure 6. Skull Fracture With Associated Epidural Hematoma on Head CT
    7. Figure 7. Skull Fracture and Small Subdural Hematoma on Head X-Ray and CT
    8. Figure 8. Skull Fracture and Subdural Hematoma on Head CT
    9. Figure 9. Skull Fracture on Head CT and 3-Dimensional Reconstruction
    10. Figure 10. Right Posterior Parietal Bone Fracture and Epidural Hematoma on Head CT
    11. Figure 11. Right Parietal Subdural Hematoma on Head CT and MRI
    12. Figure 12. Left Hemispheric Subdural Hematoma, Midline Shift, and Uncal Herniation on Head CT
    13. Figure 13. High Right Parietal Subarachnoid Hemorrhage on Head CT
    14. Figure 14. Subarachnoid Hemorrhage Compared to Diffuse Cerebral Edema on Head CT
    15. Figure 15. Frontal Lobe Contusions and White Matter Edema on Head CT
    16. Figure 16. Right Temporal Lobe Contusions on Head CT
    17. Figure 17. Cerebral Parenchymal Contusions and Subarachnoid Hemorrhage on Head CT
    18. Figure 18. Diffuse Axonal Injury on Head CT and Brain MRI
    19. Figure 19. Diffuse Axonal Injury on Head CT and Brain MRI
    20. Figure 20. Abusive Head Trauma on Head CT
    21. Figure 21. Abusive Head Trauma on Head CT and Brain MRI
    22. Figure 22. Normal Pediatric Cervical Spine on X-Ray
    23. Figure 23. Normal Cervical Spine With Pseudosubluxation on X-Ray
    24. Figure 24. Fracture at the Base of the Odontoid Process on Cervical Spine CT
    25. Figure 25. Bilateral Mandibular Fractures on Head CT and 3-Dimensional Reconstruction
    26. Figure 26. Maxillary and Mandibular Bone Fractures on CT of the Facial Bones
12. References

Abstract

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.

Introduction

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.

Figures

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References

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