Pediatric emergency medicine trisk 0819 0819
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Head trauma may cause injuries of the scalp, skull, and intracranial contents.
Although each is discussed here separately, the clinician must remember that
these injuries may occur alone or in combination, and all potential injuries must
be considered when dealing with one.
Scalp
The scalp consists of five layers of soft tissue that cover the skull; contusions and
lacerations of this structure are common results of head trauma. The outermost
layers of the scalp are skin and the subcutaneous tissue; edema and hemorrhage
here may produce a mobile swelling. The third layer, the galea aponeurotica, is a
strong membranous sheet that connects the frontal and occipital bellies of the
occipitofrontalis muscle. The remaining two layers deep to the galea are the loose
areolar tissue and pericranium. Subgaleal hematomas may result from more
forceful blows as vessels in the fourth layer bleed and dissect the galea from the
periosteum, or they may be signs of an underlying skull fracture. In subperiosteal
hematomas, or cephalohematomas, the swelling is localized to the underlying
cranial bone and most frequently occurs with birth trauma. Scalp lacerations may
occur with or without underlying contusions or fractures and they often require
suturing. Given the high vascularity of the scalp, these injuries can result in
significant blood loss if not recognized and treated appropriately.
Skull
Skull fractures occurring in the calvarium, or bony skullcap, include frontal,
parietal, temporal, and occipital fractures and may be linear, diastatic, depressed,
comminuted, or compound. Fractures in the base of the skull are termed basilar.
Most simple fractures require no intervention but are important in that they are a
marker of significant impact to the head and are associated with significantly
increased risk of TBI.
Linear fractures account for the vast majority of skull fractures in children and
often manifest with localized swelling and tenderness. Diastatic fractures are
traumatic separations of cranial bones at a suture site or fractures that are widely
split. A depressed skull fracture is present when the inner table of the skull is
displaced by more than the thickness of the entire bone. Compound fractures are
those that communicate with lacerations.
Basilar skull fractures typically produce signs specific to their fracture location
that lead to the diagnosis. Fractures of the petrous portion of the temporal bone
may cause hemotympanum, hemorrhagic or CSF otorrhea, or Battle sign
(bleeding into mastoid air cells with postauricular swelling and ecchymosis).
Fracture of the anterior skull base may cause a dural laceration with subsequent
