Radiol med
DOI 10.1007/s11547-016-0637-2
PAEDIATRIC RADIOLOGY
Diagnostic imaging of blunt abdominal trauma in pediatric
patients
Vittorio Miele1 · Claudia Lucia Piccolo2 · Margherita Trinci1 · Michele Galluzzo1 ·
Stefania Ianniello1 · Luca Brunese2
Received: 7 March 2016 / Accepted: 1 April 2016
© Italian Society of Medical Radiology 2016
Abstract Trauma is a leading cause of morbidity and
mortality in childhood, and blunt trauma accounts for
80–90 % of abdominal injuries. The mechanism of trauma
is quite similar to that of the adults, but there are impor-
tant physiologic differences between children and adults in
this field, such as the smaller blood vessels and the high
vasoconstrictive response, leading to the spreading of a
non-operative management. The early imaging of chil-
dren undergoing a low-energy trauma can be performed
by CEUS, a valuable diagnostic tool to demonstrate solid
organ injuries with almost the same sensitivity of CT scans;
nevertheless, as for as urinary tract injuries, MDCT remains
still the technique of choice, because of its high sensitiv-
ity and accuracy, helping to discriminate between an intra-
peritoneal form a retroperitoneal urinary leakage, requiring
two different managements. The liver is the most common
organ injured in blunt abdominal trauma followed by the
spleen. Renal, pancreatic, and bowel injuries are quite rare.
In this review we present various imaging findings of blunt
abdominal trauma in children.
Keywords Emergency radiology · Trauma imaging ·
Blunt abdominal trauma · Pediatric radiology · Solid organ
injury · Contrast-enhanced ultrasound · CEUS · Contrast
media · Multidetector computed tomography · MDCT
* Vittorio Miele
vmiele@sirm.org
1
Department of Emergency Radiology, Azienda Ospedaliera
S. Camillo-Forlanini, Circonvallazione Gianicolense, 87,
00152 Rome, Italy
2
Department of Medicine and Health Sciences, Università del
Molise, Campobasso, Italy
Introduction
Trauma is the main cause of mortality and morbidity in
pediatric patients, and the abdomen is the second most
common site of injury. The leading cause of injury is
related to high-energy trauma, as occurs in vehicle acci-
dents, car vs pedestrian accidents, and falls; but these
causes vary according to the age: toddlers with home-
traumas, children with sports trauma, and teenagers with
vehicle road accidents. In these conditions, a multi-organ
involvement must be considered, including not only the
abdomen but also head, chest and limbs [1, 2].
The clinical-anamnestic exam and the triage of a child
may appear very difficult, in relation to the patient’s age,
or in case of unconsciousness. At patient’s first evaluation,
the presence of bruises or wounds, together with blood and
urine exams, can help to indicate the degree of the trauma.
Therefore, diagnostic imaging plays an important role in
the complex evaluation of the injured child [3–5].
In low-energy trauma and in isolated trauma, the first
diagnostic approach in the child can be performed by
X-ray, if needed, and ultrasound (US).
Ultrasound diagnostic accuracy is highly improved
because of the introduction of contrast-enhanced ultra-
sonography (CEUS), which remarkably increases its sensi-
tivity and specificity in the early detection of solid organ
injuries.
In high-energy trauma (Fig. 1) it is possible to have two
different situations according to the hemodynamic condi-
tion; in the hemodynamically unstable young patient the
first evaluation is performed by e-FAST, which is necessary
to recognize the presence of hemothorax, pneumothorax,
and hemoperitoneum [6].
Should the hemodynamic stabilization occur, and in all
stable patients with high-energy trauma, contrast-enhanced
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Fig. 1  Blunt abdominal trauma:
flow chart of diagnostic imaging
in high-energy trauma and low-
energy trauma
CT is performed, which is the gold standard in the evalua-
tion of the injured patient [5–9].
After the initial evaluation and during follow-up pro-
cedures, the injured child must be monitored according to
radioprotection criteria (ALARA principles), keeping in
mind the patient’s medical condition and laboratory exams
[10, 11].
A child reports less frequently bone fractures (e.g., ribs)
due to a major flexibility in the bone structure of his body.
This is why the absence of bone fractures in a child does
not imply a low-level energy impact, whereas the presence
of bone fractures confirms a high-level energy trauma.
Besides, the protection provided by the lower ribs on
abdominal parenchymal organs in the child is lower, both
for the major flexibility of the ribs and for the relatively
bigger dimension of liver, spleen, and kidneys which pro-
trude from the ribs, thus being directly exposed to the
impact. The diaphragm muscle itself, which is in a more
horizontal position, pushes down the liver and the spleen
contributing to the protrusion from the ribs.
In addition, the abdominal wall is thinner; there is less
fat tissue in both subcutaneous and the intra-abdominal
site, where it wraps parenchymal organs and all structures,
partially absorbing the impact energy involved.
In the management of traumatized pediatric patient,
non-operative strategy is highly followed with respect to
an adult patient, thus requesting surgery only if strictly
needed.
Non-operative management is ideal for pediatric patients
as their blood vessels are smaller than those in adults, and
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Radiol med
there is a major vasoconstrictive response, so visceral organ
bleeding tends to be self-limited despite the severity of
trauma [12, 13].
At present, the choice of considering surgery is not
strictly linked to the severity of the lesions or to the num-
ber of organs involved, but to the capacity of normalize the
hemodynamic condition despite all the pharmacological
therapy in a maximum range of 6 h.
Liver, bowel, and spleen are highly vascularized organs,
so the risk of heavy bleeding is quite serious. In all issues,
the CT active bleeding detection is a sign of severity and
alarm, but still it does not mean that surgery is needed if
hemodynamic values are normal.
Only bowel lesions always need surgery due to the high
risk of bacterial contamination in the peritoneal cavity in
case of traumatic perforation, not like parenchymal lesions
[14].
Imaging techniques
In high-energy blunt abdominal trauma, emergency US is
performed in the emergency room on the unstable patient
through e-FAST technique to depict the eventual hemoperi-
toneum in the four standard abdominal areas. This technique
has been proved to have a high sensitivity, up to 99 % in liter-
ature review, in detecting abdominal free-fluid even in small
amounts. The aim of the exam was to depict in real-time a
huge hemoperitoneum, that may be the cause of hemody-
namic instability, which requires an immediate surgery.
Radiol med

In low-energy or localized trauma, basic US is funda-

mental not only to evaluate the presence of hemoperito-
neum but also to highlight parenchymal injuries [15–17].
For the latter purpose, its diagnostic efficiency highly
improved by the introduction of second-generation blood
pool contrast agent, performing the contrast-enhanced-
ultrasound (CEUS). CEUS is much more sensitive than
basic ultrasound in depicting parenchymal injuries and in
the evaluation of their extension. In fact CEUS has sensitiv-
ity and specificity values very similar to those of CT, which
is the gold standard. Furthermore, it can depict active
bleeding as a negative prognostic factor even if in a less
accurate way as to CT [18–21].
Few studies have been carried on the diagnostic perfor-
mance of CEUS in children [22–24], because ultrasound
contrast agents are still off-label in pediatric field. Nev-
ertheless, a large survey was performed about this topic,
including the use of contrast media in intravenous route
also: the findings suggest a favorable safety profile of
Ultrasound Contrast Agents (USCAs) in children [25].
The examination, for which it is necessary to obtain par-
ents’ informed content, requires the injection of US contrast Fig. 2  CEUS technique
medium, consisting in perfluorocarbon or sulfur hexafluor-
ide, encapsulated by a very resistent phospholipid shell,
composed by stabilized gas microbubbles (1–7 micron), possible and correct to perform a second dose of US con-
which are blood-pool agents with a non-linear reverbera- trast medium to solve any type of diagnostic doubt [30–33].
tion. They remain intravascular and produce a non-linear The main benefits of US and CEUS concern different
harmonic response that can be separated from the tissue aspects, as to its rapid performing, the accuracy and the
signal using contrast harmonic US. After the injection, a possibility of avoiding unnecessary CT exams, thus reduc-
rapid sequence exploration is done starting from the kid- ing radio-exposure risks.
neys, then the liver, and ending with the spleen (Fig. 2). CEUS limits are quite similar as those of basic US: the
The overall time needed is around 5 min. cost of contrast media, need for scanners with dedicated
The US contrast medium elimination is rapid: after softwares, longer examination times and lack of full and
around 15 min all the microbubbles break and the sulfur wide view; it is strongly operator-dependent and it does not
is eliminated through the lungs. US contrast medium has allow a complete abdominal survey because of problems
no nephrotoxic effect and it is not metabolized by the kid- related to lesion location (such as pancreas behind bowel
ney because it does not come in the interstitial space but it or stomach, aorta in obese patients, a fatty liver); but the
remains intravascular. largest limit of CEUS, also according to our experiences
Adverse reactions occur very rarely; severe reactions [34], is the poor ability to detect active bleeding and inju-
to the US contrast medium are not reported in pediatric ries to the urinary tract. As for as the latter one, we have to
patients in literature [26–28]. remember that USCAs are intravascular and are unsuitable
At CEUS exam [29], the aspect of normal parenchyma for demonstrating extravasation in the renal collecting sys-
is homogeneously hyperechoic, traumatic lesions appear as tem, also because they are characterized by lung excretion.
a non-enhancing defect, sharply demarcated from the well- CT is the imaging method of choice in the evaluation of
enhanced and healthy tissue, especially during the venous abdominal and pelvic injuries after blunt trauma in hemo-
phase, with or without capsular interruption, with morphol- dynamically stable children.
ogy and extension corresponding to the CT exam (Figs. 3, CT scans are obtained from the lower chest to the pubic
4). symphysis. In traumatic young patients, after the scout
The partial or total lack of enhancement of an organ is view it would be preferred not to perform the basal phase,
related to a vascular injury. The flow of contrast medium in order to reduce radioexposure. Unenhanced CT scan, if
micro-bubbles out of the injured organ is due to extraparen- instead performed, allows highlighting abdominal presence
chymal active bleeding. The presence of micro-bubbles of free air, parenchymal or mesenteric hematoma and bone
in the damaged area can suggest intralesional blush. It is fractures.

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 Radiol med

Fig. 3  Female child, 6 years old. a CEUS shows a triangle-shaped hepatic laceration, with anterior capsular involvement. b CE-CT, axial scan:
Note the very similar appearance of the lesion, with evidence of capsular involvement

Fig. 4  Male child, 6 years old, sport accident. a US depicts a little coronal reconstruction confirm the intraparenchymal laceration with-
inhomogenity of the liver parenchyma only. b CEUS well demon- out perihepatic fluid cllection
strates the IVth hepatic segment laceration. CE-CT, c axial scan and d

Study with oral contrast medium administration is not rec- A 3-mm thickness scan allows performing good quality
ommended, due to the little advantage compared to the com- imaging and subsequent good quality reconstructions with-
plexity of its administration in major trauma patients [35–37]. out exposure to excessive radiation.

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Radiol med
Fig. 5  Female child, 11 years old, car accident. a US and b CEUS well depict right hepatic lobe laceration with a subtle subcapsular hematoma
(white arrow). CE-CT, c axial scan and d coronal reconstruction confirm CEUS findings
The iodine intravenous contrast medium volume
depends on the patient’s weight (approximately 2 mL/kg).
The CT technique has two contrast-enhanced phases:
an arterial phase which is extended to all the body, to
depict vascular injury or active bleeding, and an abdomi-
nal portal phase, to evaluate parenchymal and hollow vis-
cera injury.
In the suspect of urinary tract injury, if the patient’s clin-
ical conditions are favorable, a later phase after 5 min is
performed.
In alternative, in case of bladder injury suspect, a retro-
grade distension with air may allow to better demonstrate
the wall injury, especially in the anterior wall.
CT exam must always be completed with bidimensional
reconstructions, on sagittal and coronal images, which are
of fundamental help in understanding the extension of the
injury. For bone component evaluation, 3D reconstructions
with volume rendering (VR) can be used.
Traumatic injuries
Liver
Hepatic lesions are to be found in 10–30 % blunt abdom-
inal trauma; in many statistics the liver is considered the
most involved organ, both with isolated lesions and with
lesions involving other organs, mainly the spleen. Lesions
are often asymptomatic and in 70 % of the cases they can
be treated in a non-operative way.
Hepatic parenchymal lesions can extend and involve
biliary ducts and blood vessels. Hemoperitoneum is pre-
sent in around 2/3 of the cases, and occurs if the lesion
involves the organ capsule (Fig. 5). If capsule is saved the
hematoma will be intra-parenchymal and/or subcapsular
(Fig. 6).
Most of hepatic lesions involve the posterior surface of
the liver, the so-called “nude area”, which is not wrapped
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Fig. 6  Male child, 4 years old. a CEUS demonstrates a right hepatic lobe’ laceration. b CE-CT, axial scan, confirms CEUS finding
by peritoneum; in these cases the blood expansion will
occur in the retroperitoneal space [38, 39].
The most used classification of the severity range of
hepatic lesions is that of the American Association for the
Surgery of Trauma (AAST). This classification divides
lesions into six categories and considers the type and exten-
sion of the parenchymal injury and the vascular involve-
ment. In pediatric patients, in which the trauma manage-
ment tends to be non-operative, the grading of parenchymal
lesion is not the main factor in the treatment decision (sur-
gical or conservative), but other elements are involved,
such as the hemodynamic stability and the multi-organ
involvement. The severity of the lesion will determine the
hospitalization period and the restrictions to be adopted
after hospital discharge.
Right hypochondrium location, immediately below the
diaphragm, rib cage, and the intestinal gas cause an even
more difficult US evaluation of hepatic dome and of the lat-
eral segments, especially in non-cooperative patients. Even
if in small amounts, the hemoperitoneum detection appears
very clear, while hepatic lesion US evaluation, especially in
the smallest lesions, can be difficult.
Lesions can present different shapes, unclear borders,
and iso-hyperechoic echostructure for the presence of fresh
blood. By CEUS the lesion will appear as an avascular
area, hypo-anechoic compared to the normal hyperechoic
parenchyma. In some cases it is possible to see the pres-
ence of hyperechoic spots due to active bleeding in the ane-
choic lesion [39–41].
In a study performed by Valentino et al. on 133 hemo-
dynamically stable patients undergoing blunt abdominal
trauma, the authors compared the diagnostic performance
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Radiol med
of CEUS with that of the CT, considered as the gold stand-
ard; CEUS revealed 81/84 traumatic injuries identified at
CT and ruled out traumatic injuries in 48/49 negative at
CT, demonstrating the high accuracy of CEUS with respect
to US, proposing this technique as a valuable first-line
approach for the early evaluation of patients with blunt
abdominal trauma [42].
In US follow-up, the size of the lesion will decrease,
changing the echostructure from iso-hyperechoic to ane-
choic in time; even the hematomas will show the same
echostructural changes together with the decrease in the
size until the disappearing of the hematoma itself. With
CEUS the avascular area will show a progressive reduction
in size and well-defined margins.
Contrast-enhanced CT well depicts a hepatic laceration
as a hypodense area, with a variable shape. When the lac-
eration reaches the capsular surface and breaks the Glis-
sonian capsule, the hemoperitoneum always occurs; this is
depictable through unenhanced CT scans, appearing as a
high-density fluid, around 40 UH.
When the laceration does not reach the capsule, hema-
toma occurs, and it can be intraparenchymal and/or subcap-
sular. When it is intraparenchymal, it is possible to depict in
basal phase CT, as a fuzzy hyperdense zone in the hepatic
parenchyma, due to recent bleeding; after intravenous
contrast medium administration, hematoma will appear
hypodense compared to the normal enhanced parenchyma;
active bleeding in the hematoma can be appreciable. Sub-
capsular hematoma typically compresses the lateral margin
of the hepatic parenchyma, thus allowing an easier differ-
ential diagnosis compared to perihepatic fluid (Fig. 7). To
carry out a prognostic evaluation, it is important to search
Radiol med
Fig. 7  Newborn, male, decelerative trauma, a CE-CT, axial scan and b coronal reconstruction show a right hepatic lobe lesion, with a large
amount of subcapsular hematoma and huge hemoperitoneum
for active bleeding in the hepatic lesion or within the hema-
toma, which appears as arterial phase contrast medium
blush, eventually followed by a pooling in later phases [38]
(Fig. 8).
Traumatic hepatic vascular lesions are rare in pediatric
patients. Avascular segments will appear hypodense after
intravenous contrast medium. When post-traumatic hepatic
artery pseudoaneurysm is seen through CT as hyperdense
focus in arterial phase within hepatic laceration, it is neces-
sary to suggest an emergency hembolization, even in case
of hemodynamic stability, as there is a high risk of rupture
(around 80 %).
The significance of periportal low hypodensity zones
has been matter of discussion; they have been consid-
ered a specific sign of hepatic trauma in the past. In fact,
this issue is not only appreciable in traumatic lesions; it
seems to be linked not only to specific organ lesion but
also to an overflow in linfatic vessels in periportal spaces,
due to a sudden increase in the central venous pressure
caused by too much fluid provided during the rescue
phase [43, 44].
During the follow-up, lesions treated non operatively
after 1 month appear hypodense, due to reabsorbing of the
corpusculated component; they gradually reduce their vol-
ume, usually to complete resolution, eventually leaving a
small parenchymal cyst or a calcification.
Complications in hepatic trauma are rare; they usually
occur in the first month and the clinical symptoms are fever,
hypotension, peritonitis, etc. Further complications may
include: ascessualization of the lesion in the first weeks:
biloma, occurring between 12 days and 6 weeks; hepatic
artery pseudoaneurysm, subcapsular hepatic hematoma due
to late bleeding and choleperitoneum.
Spleen
The spleen is the most vascularized organ of the body: in
fact around 350 L of blood flows through it every day; this
is why its injury is a potential life-threatening situation,
exposing the patient to a massive hemoperitoneum. While
in adults the spleen is partially protected by the rib cage, in
children, it is bigger and protrudes from ribs cage and it is
often involved in blunt abdominal trauma, with a frequency
of 25 % of the cases both as isolated lesion and as multior-
gan lesions.
Even for splenic lesions, as for hepatic lesions, the most
used injury severity classification is that of AAST, which is
not directly linked to the need of an operative management.
In fact, if the patient is hemodynamically stable, despite
hemoperitoneum or self-limited bleeding, the conservative
management is recommended, considering its advantages,
both because the immunitary function of the organ is pre-
served and because early and late complications caused by
surgery are prevented, shortening hospitalization. Hemody-
namic instability or the possibility of its happening is the
main factor to perform splenectomy.
Splenic injuries have different shapes, linear or branched
or complex; they can be associated to the presence of
hemoperitoneum, in case of splenic capsula rupture, or to
subcapsular or intraparenchymal hematoma, if the capsula
is undamaged, around 25 % of cases.
Hemoperitoneum linked to capsular lesion is most fre-
quent when the hilum region is involved; furthermore, in this
case, blood will flow along the splenorenal ligament at first,
but then it will reach the retroperitoneal zone, in the anterior
left pararenal space and around the pancreatic tail, as dem-
onstrated by Sivit et al. in a large series of 1744 consecutive
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Fig. 8  Male child, 5 years old, direct trauma on the right hypochon-
drium. a US shows a large traumatic involvement of the right hepatic
lobe. b CEUS clearly demonstrates the lesion extent and the presence
young patients undergoing blunt trauma [45]. The authors
demonstrated that in 96 patients with splenic blunt trauma,
extraperitoneal fluid was observed in 8 (8 %) of them,
restricted to the anterior pararenal space; this fluid was seen
to separate the splenic vein and pancreas in 25 % of cases,
and in 38 of the 1608 patients with blunt trauma not causing
splenic injury, was associated with pancreatic injury in 17/38
(45 %) children. The authors stressed to keep in mind that
fluid in the anterior pararenal space and between splenic vein
and pancreas might be seen in isolated splenic injuries, a fea-
ture useful to reduce errors in interpretation.
The spleen is considered to be a difficult organ to be
evaluated by US, because of the interposition of coasts
and the splenic flexure, especially as for as the upper pole
and the subphrenic region. Fresh blood echogenicity is
very similar to that of normal parenchyma; for this reason
it is possible to mistake traumatic lesion, even the largest.
Often, the most evident sign of splenic lesion is the pres-
ence of an hypo-anechoic fluid collection in the subcapsu-
lar or perisplenic space [46].
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Radiol med
of hyperechoic spots due to active bleeding (white arrow). CE-CT, c
Axial scan and d coronal CT reconstruction confirm size and shape
of the lesion and also the presence of active bleeding (black arrows)
Parenchymal lesions can be very difficult to recognize,
especially when perisplenic fluid is not reported. CEUS
overcomes these limits. Parenchymal lesions evaluation
must be performed during venous phase, 120–240 s after
contrast medium injection, when normal parenchyma
shows high homogeneous echogenicity which is absent in
arterial phase. CEUS aspect of splenic lesions is anechoic,
clearly highlighted as to normal hyperechoic parenchyma
The extension of the lesion to the splenic capsula and the
capsular interruption is highly recognizable. Furthermore,
subcapsular or perisplenic fluid is more visible due to the
parenchymal contrast enhancement (Fig. 9). CEUS sensi-
tivity in depicting splenic parenchymal lesions is very simi-
lar to that performed by CT, allowing a detailed follow-up
even during the bed-rest phase, without radiation exposure
[31].
The sensitivity and specificity of CT in the detection of
splenic injury is close to 100 %.
Splenic lesions are correctly shown in the portal phase,
and are usually represented by lacerations, that can involve
Radiol med

Fig. 9  Female, 8 years old, direct trauma on the left hypocondrium. a CEUS, b CE-CT: Subtle laceration of spleen lower pole (white arrow).
Low amount of perisplenic fluid collection (open arrow)

Fig. 10  Male child, 5 years old. a US: Mild inhomogeneity of the splenic lower pole. b CEUS: evidence of complete fracture of spleen lower
pole. CE-CT, c axial scan and d coronal reconstruction confirm the complete splenic fracture

the parenchyma either partially or as full thickness tear have lower severity; they can also appear in the absence of
causing the complete fracture of the organ (Fig. 10). Contu- subcapsular and perisplenic fluid. Cases of shattered spleen,
sive lesions and intraparenchymal hematomas are rare and which consists in the breaking of the organ in three or more

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Fig. 11  Young boy, 16 years old, motorcycle accident. CE-CT. a,
b Axial scans show a large traumatic splenic vascular lesion (white
arrows). c sagittal and d coronal reconstructions: evidence of post-
fragments that go along with huge hemoperitoneum, can be
clinically related to hemodynamic instability. These lesions
request urgent surgery as they represent a high death risk as
a consequence of hemorrhagic shock.
The presence of congenital clefts can lead to misinter-
pretation and false-positive patients. We have to consider
that congenital clefts have regular and homogeneous well-
defined profiles as to the lacerations that appear more irreg-
ular and are often linked to subcapsular and/or perisplenic
fluid [47, 48].
Besides being used in shattered spleen management,
operative handling is performed in case of intraparenchy-
mal active bleeding and especially in peritoneal cavity
active bleeding. Instead, in case of vascular lesions, such
as arterial-venous fistula (Fig. 11) or post-traumatic pseu-
doaneurysm, splenic artery embolization (SAE) can be
performed with a selective or super selective technique
according to angiographic results. Angiographic technique
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traumatic intraparenchymal artero-venous fistula, also well demon-
strated in e 3D VR reconstruction
is reported to be more safe compared to the surgery, and
it carries a mortality rate in the first 6 months of around
2.4 % compared to 8 %.
Urinary system: kidneys, urinary tract, bladder
and urethra
The kidneys are the third most involved organ in blunt
abdominal trauma (about 80 % of the cases), followed by
external genitals, bladder, urethra and ureter.
Parenchymal lesions are usually the result of a direct
impact, while decelerative forces cause vascular and/or uri-
nary tract lesions [49, 50].
Clinical evaluation of renal trauma in pediatric patients
is often difficult; the typical and more specific symptom
is hematuria. Gross hematuria is the most significant sign
of renal trauma, found in more than 95 % of cases, but not
always related to the severity of the trauma. In fact hematuria
Radiol med
Fig. 12  Female child, 10 years old, direct trauma to the right flank. a
US: Mild hyperechogenicity in the middle of the right kidney (open
arrow). b CEUS demonstrates a well-evident linear fracture of the
can also be found in severe traumatic lesion as in 24 % of
patients with renal artery thrombosis, and in up to 1/3 of cases
of pyelo-ureteral junction lesions. Gross hematuria is more
frequent in penetrating trauma compared to blunt trauma and
it is rare in trauma due to deceleration force.
AAST classification divides renal trauma into five
classes according to the renal damage parenchymal exten-
sion, to the urinary system involvement or to the vascular
pedicle injury. This classification is related to the devel-
opment of the prognostic factors, allowing to differenti-
ate patients with mild-to-moderate trauma (stages I–III)
requesting normal clinical-radiological observation, from
patients with severe trauma (stage IV–V) that require a sur-
gical and/or interventional treatment.
The management of renal trauma in fact is often con-
servative and operative treatment is necessary in case of
hemodynamically unstable patients, or when there is either
a complete destruction of the pyelo-ureteral junction, or a
lesion of the artery or renal vein with devascularization of
the kidney [51, 52].
kidney (white arrow), with perirenal hematoma. CE-CT, c axial scan
and d coronal reconstruction confirm the renal fracture and the perire-
nal fluid collection
The injured kidney at US exam can appear normal or
moderately swollen compared to the controlateral; some-
times a hyperechoic parenchymal zone can suggest a trau-
matic lesion (Fig. 12).
Perirenal effusion appears as an anechoic area surround-
ing the kidney. CEUS significantly increases the sensitivity
in detecting parenchymal lesions, and perirenal hematoma,
even if very small (Fig. 12). The optimal time period is up
to 2.5 min after contrast medium injection, because it is
the most effective to detect renal injuries. The two kidneys
must be explored separately with two different boluses;
their exploration can sometimes be difficult because the left
one, in particular, can be hidden by artifacts and bowel gas.
At CEUS lesions appear as hypo-anechoic areas in the
context of highly echogenic renal parenchyma. The perire-
nal fluid appears more evident due to the increased contrast
compared to the enhanced parenchyma. In case of trau-
matic vascular injury, the kidney appears partially or totally
hypo-anechoic [50]. CEUS limitations are represented by
the incomplete assessment of the retroperitoneum, by the
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Fig. 13  Female child, 9 years old a CEUS demonstrates a complete fracture of the left kidney, with perirenal fluid collection. CE-CT, a axial
scan, b coronal reconstruction and c 3D reconstruction show the renal lesion, with perirenal effusion and urine leakage (white arrow)
difficulty to detect active bleeding and by the inability to
highlight the injuries of the urinary tract, because the con-
trast agent is not excreted by the kidneys [46] (Fig. 13).
The most common renal injury is the parenchymal
contusion; it represents a bruised organ characterized by
microscopic areas of hemorrhage with edema. On CT the
involved kidney may appear larger than the other kid-
ney as a result of the associated edema. Before contrast
medium injection the renal contusion can be seen as a
hyperdense parenchymal area; after contrast medium, it
appears as a focal or diffuse region of delayed contrast
enhancement.
Renal lacerations appear as linear low-attenuation areas
in the parenchyma. The severity of the injury is linked to
the extension of the lesion: the superficial lacerations are
limited to the renal parenchyma, and the deeper ones can
separate renal fragments and more likely involve the renal
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Radiol med
collecting system (Fig. 14). Active bleeding can be detected
within the tear [50, 51].
In a series of 25 children with blunt renal and ureteral
trauma, Siegel et al. analyzed whether the extent of peri-
renal fluid collection correlated with the severity of injury.
The authors demonstrated that the perirenal or periureteral
fluid collection did not correlate with the extent of renal
injury, whereas interfascial, anterior pararenal and psoas
muscle fluid correlated in such a way with renal fracture
and pedicle avulsion [51].
A segmental renal infarct occurs in case of injury to a
segmental renal artery: at enhanced CT scan it is like a
peripheral wedge-shaped area of non-enhancing paren-
chyma. The management of renal segmental infarction is
non-operative and results in a focal area of renal scarring.
Injury to the main renal artery produces a devascularization
of the entire kidney. This is the most severe form of renal
Radiol med
Fig. 14  Male child, 11 years old, direct trauma on epigastric region.
a US shows inhomogeneous echostructure of the middle part of a
horse-shoe kidney. b CEUS demonstrates a laceration in the same
injury and must be treated promptly because permanent,
progressive loss of renal function begins 2 h after trauma.
Subcapsular or perinephric hematoma can be found in
any renal trauma. A subcapsular hematoma is limited in its
extension by the renal capsule, causing mass effect on renal
profile, whereas a perinephric hematoma is distributed
throughout the perirenal space, if it is relevant can be dislo-
cate the kidney. At the unenhanced CT scan, the hematoma
is typically hyperintense, while it becomes hypointense
after intravenous contrast medium. The assessment of any
active bleeding in the early stages after contrast medium
is very important; in fact in case of severe bleeding the
management of the patient changes from conservative to
operative.
The assessment of any lesion of the urinary tract must
be done with delayed scans. On CT images renal collect-
ing system injury results in urinary leakage of IV contrast
medium [52, 53] (Fig. 13).
Urine leakage typically remains contained in the peri-
renal space and is called as a “urinoma.” Seldom, urinary
leakage and/or hemorrhage may reach the pelvis due to
site. CE-CT, c axial scan and d coronal reconstruction confirm the
complete fracture of the middle part of the horseshoe kidney, with
separation of renal fragments
direct communication between the perirenal space in the
abdomen and the prevesical extraperitoneal space in the
pelvis. Usually the management of renal collecting sys-
tem injury is non-operative, mostly if the leak is confined
to the perirenal space; sometimes, urinary tract obstruction
requiring surgical repair may result [51].
Bladder and urethra
Due to its anatomical position, well protected by the pelvic
ring, injuries of the bladder are rare, occurring in 1–2 % of
trauma patients, most commonly secondary to blunt trauma
due to a high-energy injury. The bladder in children is con-
sidered an intraperitoneal organ in contrast to the adult
where it is considered an organ mainly extraperitoneal.
Pelvic fractures, especially those in the pelvic ring,
mostly the bilateral ones, are frequently associated with
lower urinary tract injuries, nearly 80–90 % of cases, though
only 5–10 % of pelvic fractures result in bladder injury. Two
mechanisms are involved: the first involves shearing forces
at deceleration resulting in injury at the fixed sites of pelvic
13

Fig. 15  Young girl, 16 years old, precipitation trauma (attempted suicide). a, b CE-CT, axial scans show diastasis of the pubic symphysis, with
extravesical urine leakage. In b it is possible to visualize the displacement of the balloon catheter (white arrow)
fascial attachment. The second is caused by direct injury
from pelvic bone fragments causing laceration of the blad-
der wall. Intraperitoneal blunt injury is due to rapid deceler-
ation that determines a sudden increase of intravesical pres-
sure, resulting in a “burst-type” injury.
The distention at the time of the trauma allows the rup-
ture of the bladder.
Traumatic lesion starts from wall contusion to the rup-
ture. Bladder rupture can be both intraperitoneal, extraperi-
toneal, or combined lesions.
In very young children, most of the injuries are intra-
peritoneal because of the partial intra-abdominal location
of the bladder.
Extraperitoneal bladder rupture occurs more frequently
than intraperitoneal rupture in teenagers and it is often
caused by bone spicule of a pelvic fracture, pubic symphy-
sis diastasis, sacral fractures, and sacroiliac joint diastasis
(Fig. 15).
Intraperitoneal rupture in teenagers is less frequent;
around 20 %, typically results from shearing of the dis-
tended bladder by a lap belt. However, the overall inci-
dence is lower because the pelvic fracture is also lower in
children [54–58].
Gross hematuria is believed to be associated with more
significant injuries, as in case of rupture, while micro-
hematuria has been more commonly related to bladder
contusion.
In addition to hematuria that is present in approximately
90 % of bladder trauma, the inability to void or suprapubic
pain may occur.
Imaging of the bladder, if indicated, may consist of cys-
tography and is performed in the clinically stable patient.
CT cystography is performed more liberally because of the
central role of CT scanning in trauma assessment.
The CT has 95 % sensitivity and 100 % specificity in the
detection of bladder rupture; some studies point to a lower
13
Radiol med
accuracy in intraperitoneal rupture, with values of sensitiv-
ity and specificity of 80 and 99 %. In a study performed
by Sivit et al., CT revealed IV contrast medium extravasa-
tion in all patients with bladder rupture, recognizing if intra
or retro-peritoneal in a very precise way; this latter point is
even more important knowing that an intraperitoneal rup-
ture needs surgical repair, while the extraperitoneal one
does not [54].
For CT cystography, the bladder is filled retrograde
with contrast medium and the scan is performed after 300–
400 mL of contrast is instilled. Extraperitoneal contrast
leakage is confined to the pelvis on CT and appears as a
“flame-shaped” opacity. Characteristic patterns of intraperi-
toneal contrast leakage include pooling in the cul-de-sac,
paracolic gutter, or retrohepatic space on CT or outlining of
bowel loops.
Another way to evaluate the integrity of the bladder
through CT exam is the retrograde gas distension. The
advantage is the easier air distribution which allows even in
absence of overdistension of the bladder, to hypothesize the
presence of a rupture, through the flow of extraluminal air
bubbles, even in case of small lesions, or lesions located on
the anterior wall.
Most of the extraperitoneal bladder injuries can be man-
aged conservatively with catheter drainage; in other cases,
such as for penetrating injuries, surgery is requested.
Traumatic lesions of the urethra are, for anatomical rea-
sons, more frequent in males.
Female urethral injuries are uncommon, 0–6 %, because
the urethra itself is very short, and usually all involved inju-
ries are associated with pelvic fracture as a result of lacera-
tion by bone fragments [58].
The clinical suspicion in the male is confirmed by gross
blood at the urethral meatus and/or scrotal hematoma,
while in the female by vaginal bleeding, pelvic fracture and
bleeding, perineal ecchymosis and pelvic fracture.
Radiol med
When gross blood is present at the urethral meatus, ret-
rograde urethrography (RUG) is indicated before catheteri-
zation; if blind catheter placement is performed, a partial
injury can accidentally become a complete injury.
Early management of most posterior urethral injuries
involves urinary diversion with a suprapubic catheter. Ure-
thral lesions are classified into five grade groups. Grades I
and II urethral injuries can be managed without catheteriza-
tion if the patients are able to void. Partial anterior injuries
are managed with a urethral catheter alone, and a pericathe-
ter urethrogram is performed at 7–10 days to confirm healing
before its removal. Most posterior injuries can be managed
with urinary diversion and delayed (3–6 months) reconstruc-
tion, following resorption of the pelvic hematoma.
Endoscopic techniques of primary realignment show
promise in potentially decreasing rates of stricture forma-
tion while providing equivalent results with regard to conti-
nence and erectile disfunction.
Pancreas
Pancreatic trauma is less common because of its deep posi-
tion, relatively protected by the abdominal wall and the sur-
rounding fat. In the child, however, this protection is less
effective than in the adult, due to the reduced development
of the muscle wall and the relatively poor quantity of super-
ficial and deep adipose tissue and, owing to its retroperito-
neal location, mortality is quite high, ranging from 70 to
80 % when there is also involvement of aorta, the superior
mesenteric artery or vena cava.
The pancreatic trauma happens in 3–12 % of blunt
abdominal trauma: it rarely occurs as isolated injury but usu-
ally 60 % of cases are associated with lesions of the liver,
spleen or the duodenum. This means that in patients with
pancreatic lesions morbidity and mortality increase [59, 60].
The detection of lesions limited to the parenchyma may
allow conservative treatment, while in case of duct injury
the management depends on the site of the lesion. If the
distal portion on the left side of the spine (grade III) is
involved, duct stenting or surgery for partial resection of
the pancreas is needed. Lesions in the proximal part of the
duct are of greater severity (grade IV), but surgical treat-
ment is more complex for their deep location; therefore,
they are managed more often by the positioning of a stent,
preventing surgery.
The pancreatic trauma is the leading cause of pancreati-
tis in children.
Because of its deep position and the interposition of
intestinal gas content, the pancreas is a difficult organ to
evaluate through US exam; however, in children the evalu-
ation is easier, mainly because of their physical structure.
The pancreatic lesions typically appear as total or par-
tial glandular lacerations, in this case with organ separation
into two parts.
The direct sign of injury is the detection of a tear as a
hypoechoic intraparenchymal rhyme; it can be difficult
to find it on ultrasound exam. Indirect signs can be more
easily depictable: focal or diffused pancreatic swelling,
unclear organ profiles, focal or diffuse hyperechogenicity
of the parenchyma and presence of fluid periglandular col-
lection [46].
There are few reports on the use of CEUS in pancreatic
trauma [60].
In one of these, Lv et al., in a series of 22 consecutive
patients undergoing blunt pancreatic trauma, reported an
excellent sensitivity of CEUS in detecting pancreatic inju-
ries compared with CT as the gold standard. The authors
stated that CEUS may be a promising technique, especially
in those departments where it is performed as an initial
diagnostic tool.
Other authors stated that CEUS can detect parenchymal
and capsular injuries with excellent imaging characteris-
tics, although it should not be intended as a substitute for
CT but a possibility to boost US role in the screening of
pancreatic trauma (Fig. 16).
CT exam shows specific and non-specific signs of pan-
creatic trauma.
The generic and/or non-specific signs may include:
enlargement of the gland, soffuse hypodense undefined
profiles as occurs in contusion; thickening of the renal fas-
cia and hyperdensity of peripancreatic adipose tissue. The
presence of hypodense fluid due to lesion of the pancreatic
duct, or the presence of hyperdense fluid in case of hema-
toma within the anterior pararenal space and/or periglandu-
lar, although not specific, is a good indicator of pancreatic
trauma and can suggest the suspicion of traumatic lesion.
The presence of peritoneal fluid is also a non-specific
sign. The following are the direct signs: one or more lin-
ear hypodense images after intravenous contrast medium
crossing the gland more or less deeply, that are expression
of tearing, while separated glandular fragments will appear
in the transections (Fig. 17).
CT is able to diagnose indirectly the involvement of the
pancreatic duct, in relation to the depth of glandular lesions.
Periglandular post-traumatic collections, due to duct injury,
often evolve into pseudocysts and tend to resolve spontane-
ously or be subsequently subject to percutaneous drainage
or surgery [3, 5].
13

Fig. 16  Male child, 8 years old, direct trauma. a US and b CEUS
depict enlargement of the pancreatic tail: CEUS shows mild
hypoechogenicity of the echostructure (white arrow) also. c, d Axial
Rare abdominal injuries
Bowel and mesentery
Bowel injury is uncommon after blunt trauma in children.
Due to the anatomical central position in abdominal
cavity and to the fixation due to Treitz ligament, lesions of
duodenum and proximal portion of jejunum are more fre-
quent (Fig. 18).
Isolated viscera lesions are usually difficult to diagnose;
CT alone cannot be used as a screening tool for hollow vis-
cus injury because its sensitivity and specificity are approx-
imately 55 and 92 %, respectively.
Even clinical signs and symptoms may be absent, mini-
mal, or delayed.
The suspecion of hollow viscus injury comes from
clinic data, type of trauma, possible presence of super-
ficial abdominal wall bruising and from diagnostic
imaging.
US does not usually detect bowel injury; it can demon-
strate indirect signs as free fluid between bowel loops.
13
Radiol med
CT scans confirm the pancreatic tail enlargement and demonstrate a
pancreratic tail lesion, with a peripancreatic fluid collection
As to the abdominal free air presence, depictable
through direct abdominal X-ray exam, we must know that
the small bowel contains less air than the large bowel and
thus in case of perforation it will be possible to detect intes-
tinal contents around the injured loop and a small quantity
of free air compared to a large bowel perforation.
CT exam shows specific and non specific signs [14, 61].
Specific signs include the tear of intestinal wall and the
presence of free peritoneal or retroperitoneal air which
is found by CT exam only approximately in 30–50 % of
cases. The bowel wall thickening, usually eccentric, close
to the contusive lesion, especially in the duodenum, sug-
gests intramural hematoma. The leakage of the contrast
medium through oral administration outside of the intes-
tinal lumen is a highly specific sign; however, it not very
sensitive. Moreover, the use of oral contrast medium is
not widely used in the traumatized patient because it takes
more time in carrying out the exam.
The complete rupture of the intestine most commonly
occurs in the mid to distal part of the small intestine. The
most common site is the jejunum.
Radiol med
Fig. 17  Male child, 8 years old. CE-CT, a–c Axial scans show the fracture of the left hepatic lobe (open arrow) and the laceration of the pancre-
atic head (white arrow). d Coronal CT reconstruction confirms the deep laceration of pancreatic head (white arrow)
Non specific signs of bowel or mesenteric injury include
mesenteric hematoma, which appears as a limited fluid col-
lection of considerable size, in which may be seen active
bleeding (Fig. 19); free fluid in the abdomen; “mesenteric
stranding” due to mesenteric fat thickening.
Adrenal glands
Because of the presence of retroperitoneal fat, that protects
adrenal glands, traumatic lesions of these glands are very
rare in pediatric patients.
The frequency is around 0.15–4 % of blunt abdominal
trauma, usually in multiorgan lesions (Fig. 20); isolated
adrenal injury occurs in around 2–6 % of cases. Traumatic
adrenal lesions are more frequent in high-energy trauma
with an injury severity score (ISS >15), associated with
other lesions up to 50 %.
Usually traumatic adrenal lesion is unilateral (>90 %)
with a considerable prevalence for the right adrenal gland
(85–90 %), depending on three main causes: abrupt com-
pression between the liver and lumbar vertebral bodies; the
damage of small vessel due to a deceleration; the sudden
increase of adrenal venous pressure due to a compression
of inferior cava vein (IVC) that highly influences the right
adrenal gland because right adrenal vein drains directly in
IVC. This is the reason why it is influenced more than the
left adrenal vein that drains in left renal vein.
Lesions are usually asymptomatic, so their detection is
accidental.
US technique has low sensitivity in detecting traumatic
adrenal lesions, especially for their association with multio-
rgan lesions, rib fractures and pneumothorax.
CT is the gold standard exam in detecting traumatic
adrenal gland lesions. Main CT details are hematoma
around 60–83 %, overall adrenal hemorrhage around
9–43 %, the homogeneous swelling of the adrenal gland
around 10 %, and the adrenal rupture that is very rare.
Furthermore, it is possible to detect signs associated with
traumatic lesion such as hemorrhagic suffusion of periadre-
nal fat, retroperitoneal hemorrhage and active bleeding.
Unrecognized adrenal lesions can cause late hemorrhage
and infections. In case of massive hemorrhage, IVC can be
compressed causing thrombosis.
Bilateral traumatic adrenal lesions are very rare, less
than 1 %; it is still unknown if they can cause severe endo-
crin abnormalities, i.e. acute adrenal failure [62].
13
 Radiol med

Fig. 18  Female child, 6 years old, direct trauma on epigastric region. strate a large hematoma of the third duodenal portion, displacing and
a US shows a large fluid collection strictly close to a bowel loop. narrowing the intestinal lumen
CE-CT, b axial scan, c coronal and d sagittal reconstruction s demon-

Fig. 19  Young boy, 16 years old, microcar accident. a Axial CT scan and b coronal CT reconstruction show a fluid collection in the mesentery
of the right hypochondrium, with active bleeding (white arrow)

13
Radiol med
Fig. 20  a, b Axial CT scans, c coronal and d sagittal reconstructions demonstrate a traumatic lesions of liver, spleen and right kidney. It is also
appreciable a large adrenal hematoma, with active bleeding (white arrow)
Hypoperfusion complex
Regardless of the hypovolemic shock causes, the radi-
ologist must recognize and identify a complex set of CT
details indicating a severe hypoperfusion and that are sug-
gestive of a transition state between severe but compen-
sated hypovolemia and the decompensated state. In these
cases we have a caliber reduction of aorta and inferior cava
vein, a widespread fluid distension of intestinal bowel with
thickened and irregular enhancement of bowel wall after
contrast medium injection (shock bowel).
There will be a considerable enhancement of the mesen-
tery, kidneys and adrenal glands, which will then decrease
in the pancreatic and spleen parenchyma. It is possible to
find periportal low-attenuation zones, peritoneal and retro-
peritoneal fluid.
The detection of these CT details suggesting hypoperfu-
sion is a predictor of a poor outcome; in fact the reported
mortality rate in children with this set of findings at CT is
more than 80 % and many of these children have severe
associated multisystem injury [63, 64].
Conclusions
In a traumatic setting the triage of a child may appear very
difficult; therefore, diagnostic imaging plays an important
role in the complex evaluation of an injured child [3–6].
In low-energy trauma and in isolated trauma, the first
diagnostic approach in the child can be performed by
X-ray, if needed, and ultrasound (US), whose diagnostic
accuracy is highly improved because of the introduction
of Contrast Enhanced Ultrasonography (CEUS), which
remarkably increased its sensitivity and specificity in the
early detection of solid organ injuries [18–21, 33, 34,
46].
In high-energy trauma, in the hemodynamically unstable
young patient, the first evaluation is performed by e-FAST
13

to recognize a possible hemothorax, pneumothorax, and
hemoperitoneum.
In all stable patients with high-energy trauma, and in
those who have been stabilized, contrast-enhanced CT is
performed, which is the gold standard in the evaluation of
the injured patient [5–9].
When performing a CT scan in a young patient one
should always keep in mind the ALARA principles,
because children are particularly susceptible to the associ-
ated increased risk of developing malignancy later in life
[10, 11]. Neverthless, the use of CT in the injured child
allows a quick evaluation of the entire body in a rela-
tively few time, resulting in improved triage and reducing
morbidity and mortality. In addition, it has enormously
contributed to shift from an operative to a non-operative
management.
CT staging of solid injuries has been shown to be useful
for estimating the time course of healing. However, some
authors stated that the follow-up imaging of solid injury in
asymptomatic children who sustained low-energy or an iso-
lated trauma is probably not necessary [3]. Nevertheless, in
the recent years some research advocated the application of
CEUS in the follow-up of patients with trauma conserva-
tively managed until discharge, both in order to reduce
unnecessary CT examinations and to overcome poorly vis-
ible traumatic injuries at conventional ultrasound, better
revealed using USCAs [33, 53, 65–67]. Taking into account
some limits of CEUS, such as being operator-dependent, a
low coverage and the inability to detect some possible com-
plications, such as bilomas, abscesses, urinary tract, and
vascular lesions, the authors obtained interesting results in
the follow-up of a cohort including 152 patients, many of
them children, with low-energy trauma who underwent fol-
low-up with both CEUS, performed at 24 and 72 h and at
1 month from trauma, together with MR [68]. In this series,
MR allowed to better depict the integrity of urinary tract
(not visualized by CEUS) and to highlight the presence of
two adrenal glands injuries, dismissed by CEUS. So, due to
its panoramicity, and its high contrast resolution, MR per-
mits a better morphological and temporal trauma staging
with respect to the CEUS and allows excluding all negative
prognostic factors, such as late bleeding, rupture of the uri-
nary tract or additional injuries. Moreover, its role is even
more important considering the age of these patients, mak-
ing this technique extremely profitable compared to CT.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict
of interest.
Ethical standards This article does not contain any studies with
human participants or animals performed by any of the authors.
13
Radiol med
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