Inflicted abdominal and thoracic injury — formative SAQs

SAQ 1 (10 marks)

A 14-month-old presents with two days of vomiting, abdominal distension and fever. The carer attributes it to a 'tummy bug'. On examination the abdomen is rigid and guarded. You note a faint bruise over the flank. ^[1]

1. What injury patterns carry the highest specificity for inflicted abdominal injury, and why? (3) ^{[1] [4]}
2. Explain why a 'soft' early abdomen does not exclude a serious hollow-viscus injury. (2) ^[4]
3. Outline the laboratory occult-injury screen you would request and the imaging strategy for a stable child. (3) ^{[3] [9]}
4. State the safeguarding steps that must run concurrently with surgical management. (2) ^[1]

Model answer

1. Duodenal and jejunal injury, pancreatic injury, and mesenteric injury carry the highest specificity because they require substantial, directed force on retroperitoneal or mobile viscera that a short fall cannot generate; a hollow-viscus perforation in a pre-verbal child is abuse until proven otherwise. ^{[1] [4] [8]}
2. Full-thickness duodenal or jejunal perforation leaks enteric contents and peritonitis with sepsis builds over 24–48 hours, so the abdomen may be soft initially and a rigid abdomen is a late sign; delayed presentation is itself a marker of abuse. ^[4]
3. Draw AST and ALT (liver), lipase and amylase (pancreas), troponin if chest injury, FBC, lactate, coagulation and group-and-save; for a stable child, request contrast-enhanced CT of the abdomen and chest and a high-detail skeletal survey with oblique rib views, repeated at two weeks in any child under two. ^{[3] [7] [9]}
4. Notify the child-protection team during resuscitation, file the mandatory report required by jurisdiction, document and photograph injuries, and convene a multi-disciplinary case conference; never discharge to the index household before the assessment is complete. ^[1]