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population (see Chapter 87 Child Abuse/Assault ) Major blunt abdominal trauma resulting from physical abuse is uncommon but highly fatal in children; mortality rates are as high as 50% This high fatality rate is the result of the unfortunate but typical delay with which parents or caregivers who abuse children seek treatment FIGURE 103.10 Plain radiograph of the lumbar spine of a 15-year-old boy lap belt only– restrained passenger in a motor vehicle crash over an embankment There is a transverse Chance fracture of the vertebral body and posterior elements of L2 The lap belt complex in this patient also included a small bowel contusion, pancreatic head contusion, a focal area of aortic disruption (dissection) just inferior to the renal arteries, and a retroperitoneal hematoma FIGURE 103.11 Intraoperative photograph of a segment of small bowel of a 15-year-old boy who was a lap and shoulder belt–restrained back seat passenger in a motor vehicle collision Initial examination revealed ecchymosis below the umbilicus and significant tenderness upon palpation of the lower abdomen Findings at laparotomy included near transaction of the terminal ileum with devitalized tissue at the edges of the injury Children who are seriously injured because of physical abuse commonly have more than one site of trauma; some of the injuries can be occult, and others may have been inflicted at different times Abdominal injuries are usually inflicted by fists, feet, or small handheld objects and are rarely penetrating The diagnosis of blunt abdominal injury caused by battering is difficult to make unless a high index of suspicion for child abuse is maintained An important clue is often an implausible historical account for the seriousness of the injury As with abdominal trauma caused by other mechanisms, physical examination findings may not be obvious Laboratory analyses and abdominal CT may be necessary to confirm the diagnosis Severe injuries may present with obtundation and shock, abdominal distention, and tenderness Intra-abdominal injuries most commonly involve the liver and the spleen, as well as the pancreas–duodenum–jejunum region In all such cases in which child battering is suspected, a child protection consultant should be involved early Suggested Readings and Key References Initial Evaluation and Management of Abdominal Trauma Adelgais KM, Kuppermann N, Kooistra J, et al Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries J Pediatr 2014;165:1230–1235.e5 Holmes JF, Lillis K, Monroe D, et al Identifying children at very low risk of clinically important blunt abdominal injuries Ann Emerg Med 2013;62:107– 116.e2 Schonfeld D, Lee LK Blunt abdominal trauma in children Curr Opin Pediatr 2012;24:314–318 Subcommittee on Advanced Trauma Life Support of the American College of Surgeons Trauma Committee Advanced Trauma Life Support for Doctors 9th ed Chicago, IL: American College of Surgeons; 2013 Management of Blunt Abdominal Trauma Gaines BA Intra-abdominal solid organ injury in children: diagnosis and treatment J Trauma 2009;67(2 Suppl):S135–S139 Iqbal CQ, St Peter SD, Tsao K, et al Operative vs non-operative management for blunt pancreatic transection in children: multi-institutional outcomes J Am Coll Surg 2014;218:157–162 Leeper CM, Yazer MH, Cladis FP, et al Use of uncrossmatched cold-stored whole blood in injured children with hemorrhagic shock JAMA Pediatr 2018;172:491–492 Marwan A, Harmon CM, Georgeson KE, et al Use of laparoscopy in the management of pediatric abdominal trauma J Trauma 2010;69:761–764 Wood JH, Partrick DA, Bruny JL, et al Operative vs nonoperative management of blunt pancreatic trauma in children J Pediatr Surg 2010;45:401–406 Management of Penetrating Abdominal Trauma Adesanya AA, da Rocha-Afodu JT, Ekanem EE, et al Factors affecting mortality and morbidity in patients with abdominal gunshot wounds Injury 2000;31:397–404 Berardoni NE, Kopelman TR, O’Neill PJ, et al Use of computed tomography in the initial evaluation of anterior abdominal stab wounds Am J Surg 2011;202:690–695 Boleken ME, Cevik M, Yagiz B, et al The characteristics and outcomes of penetrating thoracic and abdominal trauma among children Pediatr Surg Int 2013;29:795–800  ... 2018;172:491–492 Marwan A, Harmon CM, Georgeson KE, et al Use of laparoscopy in the management of pediatric abdominal trauma J Trauma 2010;69:761–764 Wood JH, Partrick DA, Bruny JL, et al Operative