Case 33

A 2-month-old infant who had been delivered by a forceps delivery had presented to the family physician with ill-defined scalp swelling noticed 4 days previously. There was no history of recent injury. He was very irritable. A rash over his chest had appeared that day. He was referred to paediatrics for assessment and the ‘rash’ over the chest looked like fingertip bruising. The infant’s skull x-ray is shown (Image 33). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig33.jpg"/>

What do you notice on the skull x-ray (Image 33)?

What would you do?

Is any further imaging needed? If so, what would you request and in view of the irritability what might you find? What is the significance of the findings?

76The x-ray showed a widened skull fracture in the right parietal bone extending from the coronal suture to the lambdoid suture. While any unexplained skull fracture is suspicious for non-accidental injury, a widened skull fracture has a higher association, implying more force at impact. ¹ A skull fracture implies forceful hard impact which may be accidental or not. It may be associated with shaking injury (shake and throw injury). Finding scalp swelling over this means it is a recent injury (possibly up to 7 days old).

A thorough clinical evaluation is essential, in case the ‘rash’ is related to sepsis and appropriate treatment should be started as necessary. In addition, further assessment for trauma should be considered. Coagulation tests, bone biochemistry, ophthalmic assessment and a full skeletal survey were normal in this case. However, the clinical history of unexplained scalp swelling is suspicious for trauma.

Logically it would have been more appropriate to request a CT scan initially to look for intracranial complication of trauma. The CT involves radiation but is available in most hospitals without the need for starvation in a 2-month-old. MRI saves radiation, but is less widely available and is intolerant of patient movement without sedation or anaesthesia. Acute blood on MRI is much more difficult to identify than on CT for a non-specialist. Cranial ultrasound has almost no general application in suspect trauma. A neuroradiological opinion revealed no intracranial complications. Ophthalmology, skeletal survey and bone biochemistry were normal. The issue of how a complex skull fracture occurred remains, without any revealed history of trauma on serial questioning. A carer may conceal an accidental injury or a carer may know about a non-accidental injury but decline to reveal it for fear of consequences. If there is no admission, it may be difficult to exclude either the mother or father as perpetrators. The presence of recent ‘fingertip bruising’ caused additional concern about non-accidental injury and a full child protection investigation was initiated.