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Importance of Costal Margin Tenderness and Risk for Intra-Abdominal Injury in Children with Blunt Abdominal Trauma
Katherine Flynn-O'Brien, MD, MPH, University of Washington, Seattle WA; Nathan Kuppermann, MD, MPH and James F. Holmes, MD, MPH, UC Davis School of Medicine, Sacramento CA

Abstract: Introduction: The risk of radiation exposure from computed tomography (CT) imaging in children is well recognized. History and physical exam findings, including costal margin tenderness (CMT), influence a physicianís decision to image a child with blunt abdominal trauma. Methods: To determine the risk of intra-abdominal injury (IAI) in children presenting with isolated CMT and with CMT in conjunction with other identified risk factors, we completed a planned secondary analysis of a large prospective multicenter cohort study, including 9174 children with a GCS 14-15 and complete data for CMT and other previously published predictors of IAI. Results: A total of 1267 children presented with CMT: 177 with isolated CMT and 1090 non-isolated CMT. No patients with isolated CMT were found to have IAI (0/177; 0%, 95% CI 0.0-1.7%), compared to 17.2% (187/1090; 95% CI 15.0-19.5%) presenting with non-isolated CMT. The risk difference comparing IAI in the setting of isolated risk factors (abdominal pain, evidence of abdominal wall trauma, etc.) to IAI with the same risk factor and CMT was at most 5.5% (-10-21%), and was not statistically significant for any previously identified risk factors for IAI. About 1 in 5 of all children with isolated CMT received a CT scan of the abdomen (20.3; 14.7-27.0%). Conclusion: In the setting of isolated CMT, abdominal CT scan for evaluation of IAI is of low yield. The attributable risk of IAI due to CMT in the setting of other history and physical exam findings is minimal.

Objective:
Discuss the importance of costal margin tenderness on risk of intra-abdominal injury in blunt pediatric trauma, both in isolated and in combination with other known predictor variables.
Objective Content:
Costal margin tenderness alone does not appear to be associated with intra-abdominal injury in children after blunt trauma. Furthermore, costal margin tenderness, when added to other isolated history and physical exam findings, appears to minimally increase the risk of intra-abdominal injury. In these children, CT scan may reasonably be avoided.


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