Volume 7, Case 8
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 2 year old who was run over by a truck. A heavy delivery truck was driving forward slowly in a delivery service area. This 2 year old child dashed out in front of the truck. She fell forward as she was struck by the bumper. The front tire rolled over her body prone on the pavement from the buttocks toward her left shoulder. She was crying and her parents who noticed what happened immediately carried her into their car and they drove to the hospital.
Exam: VS T37, P140, R40, BP 100/65, oxygen saturation 94% in room air. She is crying, alert and cooperative. She follows commands well. Her head shows no tenderness, bruising or abrasions. Pupils are reactive. Vitreous is clear bilaterally. No facial abrasions or bruises. TM's are normal. Teeth are intact without evidence of oral injury. Her neck is non-tender. Her neck range of motion is not restricted since she was carried in by her mother without any previous immobilization. Heart regular. Lungs clear, but she has an occasional grunting character to her breathing. Her oxygen saturation rises to 100% when placed on oxygen by mask. Her anterior chest shows no bruises. Her abdomen is soft with active bowel sounds. No definite tenderness is present. There is extensive bruising over her anterior pelvis. There is no bleeding. Her labia are bruised but no bleeding or tears are noted. Her upper extremities are non-tender and her lower extremities are non-tender distal to the pelvis. Her back shows mild bruising in the upper chest and the buttocks. She can move all her fingers and toes well. She does not move her lower extremities spontaneously. There are no extremity deformities noted. Her color and perfusion are good.
Her airway and breathing are assessed as being satisfactory at this time with the oxygen by mask. An IV is started and laboratory studies are ordered. Her circulatory status is assessed as being satisfactory at this time. Portable radiographs of her neck, chest, abdomen and pelvis are obtained.
View her neck radiographs (below)
View her chest radiographs (below)
View her abdominal radiographs (below)
View her pelvis radiographs (below)
Her lateral neck radiograph is normal although C7 is not visible. Her neck is non-tender and her range of motion is good so no further neck radiographs are ordered.
An AP view of her chest obtained in the supine position does not identify any fractures of the clavicles or ribs. Examine the chest radiograph again for any acute injuries.
View CXR.
There is a pneumothorax on the left and haziness in the left upper lobe most likely due to a pulmonary contusion. The left pneumothorax is not obvious because the patient is supine. It is best seen as an air density along the left heart border. It extends inferiorly and is best seen over the left diaphragm along the left heart border.
The arrows below identify the pneumothorax
Her abdominal flat plate is normal, but her pelvis demonstrates bilateral pelvic rami fractures and a fracture of the proximal left femur.
The arrows below point out the fractures
The pneumothorax and pulmonary contusion here are small and difficult to see and it could have been easily missed. A pulmonary injury of some type should have been suspected based on her grunting respirations and mild hypoxia. A pneumothorax is best seen on chest radiographs with the patient in the upright position. Small pneumothoraces may not be visible on supine chest radiographs. In this case, no other treatment (in addition to oxygen) was required for the pulmonary contusion and the pneumothorax.
CT scans of her head, chest and abdomen were completed. Her head CT was normal. Her CT scan confirmed the small left pneumothorax and left upper lobe pulmonary contusion. Her abdominal CT was normal.
Her fractures were managed by an orthopedic surgeon with a good outcome.