Tracheal trauma is secondary to compression injuries, penetrating wounds, or of iatrogenic origin (traumatic intubation) [3]. These are serious conditions that can lead to severe respiratory failure and hemodynamic instability. Diagnosis can sometimes be difficult given the paucisymptomatic presentation of some patients with small lesions [5,6].

The specific anatomy of children helps reduce the incidence of this type of trauma: their relatively wide cephalic extremity and rib cage protect a relatively short neck. In addition, the mobility and compressibility of the tracheal cartilages further reduce the risk of injury [3]. However, once the trachea is injured, it is important to provide prompt treatment. A small larynx, larger arytenoids, and a prominent epiglottis contribute to a narrowing of the laryngeal lumen and complicate ventilation [7]. The main mechanism of tracheal injury in children remains external compression directly applied to the anterior aspect of the neck. Falls on playgrounds and bicycle accidents are the most common causes: at the moment of impact, the child's neck is hyperextended and the exposed larynx hits the handlebars (Padded Dash Syndrome) [8]. The cartilage then compresses, and the transmitted force is transmitted to the posterior tracheal wall, which compresses the cervical spine. This phenomenon mainly results in horizontal or irregular linear lesions of the posterior wall. In contrast, iatrogenic tracheal injuries result in longitudinal lesions of the posterior wall [9]. Most of these lesions are located 2.5 cm above the carina or at the level of the right main bronchus [10].

The most common clinical signs are subcutaneous emphysema, respiratory distress, and hemoptysis. Some patients may also present with pneumothorax or pneumomediastinum [1,3–6,9]. However, it is important to keep in mind that many patients may present with few symptoms. For any patient suspected of tracheal trauma, the priority remains to ensure good ventilation. This may involve evacuation of a pneumothorax, resuscitation, or endotracheal intubation if the patient is unstable. A complete injury assessment must then be performed: this includes a chest X-ray to look for a pneumothorax, pneumomediastinum, or to assess subcutaneous emphysema; an interruption of the tracheal air column or atelectasis are highly suggestive. This assessment must be combined with X-rays of the cervical spine to look for fractures of the spine or rib cage [3]. The role of cervicothoracic CT scan varies according to the authors. It may delay treatment and should therefore not be preferred when the patient is unstable [1,3,5]. However, it is very useful in stable patients with abnormalities detected on the chest X-ray. It allows for a complete assessment of the spine and provides a precise lesion (tracheal injury) and peri-lesion cervicothoracic assessment (esophageal, pulmonary, aortic involvement) [4,9].

The gold standard for diagnosing tracheobronchial trauma remains bronchial endoscopy. It should ideally be performed by a pulmonologist or thoracic surgeon in the operating room [1,3–5,9]. It allows for a precise lesion assessment, the determination of a possible surgical indication, and the provision of visually controlled endotracheal intubation, excluding the lesion if necessary. However, given the quality of the images and the precision of the reconstructions of the tracheobronchial tree currently available in the recent scanners, the role of this invasive examination can, in our opinion, be debated. Furthermore, conservative management should be considered as a matter of principle for these injuries, particularly in pediatrics and in the absence of signs of severity.

Management of tracheal injuries after stabilization of the patient is dictated by the patient's clinical condition and the characteristics of the injury. In case of respiratory and hemodynamic stability, conservative treatment based on systemic corticosteroids, proton pump inhibitors and possibly antibiotic prophylaxis can be undertaken [9]. In cases of respiratory instability with preserved hemodynamics, or in cases of severe tracheal lesions (circular lesion involving the entire tracheal thickness, > 2 cm, involvement of the pericarial region), reconstructive surgery is indicated. Finally, in the event of hemodynamic and respiratory instability, surgery not being possible, extracorporeal circulation techniques (extracorporeal membrane oxygenation [ECMO]) can be used [5]. In our case, the severity of which was moderate, with preserved respiratory function, a chest CT scan appeared to be the first-line examination, avoiding all the potential complications of an emergency bronchial endoscopy. It also did not seem necessary to perform a bronchial endoscopy immediately afterward, since the lesions had been clearly visualized on the CT scan and were deemed minimal, and respiratory function was always preserved.