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.