Physical Examination Is the Best Predictor of the Need for Abdominal Surgery in Children Following Motor Vehicle Collision

Natalie A. Drucker, MD; Lucas McDuffie, MD; Eric Groh, MD; Jodi Hackworth, MPH; Teresa M. Bell, PHD; Troy A. Markel, MD


J Emerg Med. 2018;54(1):1-7. 

In This Article

Abstract and Introduction


Background Exploratory laparotomy in children after motor vehicle collision (MVC) is rare. In the absence of definitive hemorrhage or free abdominal air on radiographic imaging, predictors for operative exploration are conflicting.

Objective The purpose of this study was to explore objective findings that may aid in determining which children require operative abdominal exploration after MVC.

Methods Data from 2010–2014 at an American College of Surgeons–certified level 1 pediatric trauma center were retrospectively reviewed. Demographics, vital signs, laboratory data, radiologic studies, operative records, associated injuries, and outcomes were analyzed and p < 0.05 was considered statistically significant.

Results Eight hundred sixty-two patients 0–18 years of age presented to the hospital after an MVC during the study period. Seventeen patients (2.0%) required abdominal exploration and all were found to have intraabdominal injuries. Respiratory rate was the only vital sign that was significantly altered (p = 0.04) in those who required abdominal surgery compared with those who did not. Physical examination findings, such as the seat belt sign, abdominal bruising, abdominal wound, and abdominal tenderness, were present significantly more frequently in those requiring abdominal surgery (p < 0.0001). Each finding had a negative predictive value for the need for operative exploration of at least 0.98. There were no significant differences in trauma laboratory values or radiographic findings between the 2 groups.

Conclusion Data from this study solidify the relationship between specific physical examination findings and the need for abdominal exploration after MVC in children. In addition, these data suggest that a lack of the seat belt sign, abdominal bruising, abdominal wounds, or abdominal tenderness are individually predictive of patients who will not require surgical intervention.


Unintentional injury is the leading cause of death in children >1 year of age, and motor vehicle collision (MVC) is the leading cause of death in children 8–18 years of age.[1,2] Seat belt use is a crucial method to decrease the risk of severe injury and death in children involved in MVC.[3,4] However, shortly after the introduction of seat belts in 1960, the "seat belt syndrome" was described—a combination of abdominal wall bruising (AWB), intra-abdominal injury (IAI), and lumbar spine fracture—raising concern that seat belts may cause a unique set of injuries.[5] Subsequently, multiple reports found that a positive seat belt sign (SBS) was associated with an increased risk for IAI.[6–11] In addition, children remain at increased risk for seat belt–related injury caused by improper restraint use.[12,13] The probable mechanism of seat belt injury is direct loading over the injured organ.[14]

The optimal evaluation algorithm to identify blunt IAI in the pediatric population includes a combination of history and physical examination findings, laboratory values, and imaging modalities.[15–21] The majority of pediatric blunt IAIs are managed conservatively; however, the need for abdominal exploratory surgery persists in select circumstances.

Literature describing predictive factors for the need for abdominal exploratory surgery in pediatric patients presenting with blunt trauma after MVC is scarce. A study of 1400 patients over a 3-year period at a major trauma center concluded that SBS was associated with a higher incidence of IAI.[9] Likewise, Paris et al. concluded that associated lumbar fracture, free intra-abdominal fluid, and tachycardia were highly predictive of intestinal injury in children with AWB and the need for laparotomy after MVC.[8] However, this study was limited to patients presenting with AWB and may have missed patients with IAI in the absence of this physical examination finding. Other studies have presented conflicting data, and have suggested that the SBS is not associated with an increased risk of abdominal injury or need for abdominal surgery.[22,23]

The objective of the present study was to determine predictive factors associated with the need for abdominal exploratory surgery in children sustaining blunt abdominal injury after MVC. We hypothesized that a combination of laboratory, physical examination, and radiographic findings would be predictive of the need for operative intervention in children with blunt abdominal trauma.