Case 71

A 4-year-old girl was brought to the emergency department by her father. He states she fell off the sidewalk and bumped her head. The next morning she woke up with a swollen head and swollen eyes, as shown in Images 71a-71c. The father denied any further history of trauma. The child refused to answer questions in the emergency department. The following photos show her front face (Image 71a), right (Image 71b) and left sides (Image 71c) of her face, respectively. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig71a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig71b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig71c.jpg"/>

What finding do you see?

What tests and imaging are important to determine the aetiology of this patient’s presentation?

Why did the child refuse to answer questions?

162

Examination of this child revealed a palpable, doughy swelling which was present both in the forehead as well as the hard skull areas. This is consistent with a subgaleal haematoma, which results from bleeding beneath the galea. It also resulted in tracking of the blood to the periorbital area, especially on the left side as noted in Image 71c. Mechanisms for subgaleal haematomas include falls, hair pulling, hair braiding and vacuum extraction with vaginal delivery. ¹ The bleeding is located between the periosteum and the scalp’s galea aponeurotica. Unlike cephalohaematomas, which are restricted by suture lines, subgaleal haematomas can cross suture lines and lead to significant blood loss and hypovolemia. The subgaleal space communicates anteriorly over the superior orbital ridge with the superior orbit, allowing blood to track into the periorbital space. ² This can lead to swelling as in this child or proptosis and visual compromise.

A full evaluation for child abuse is necessary. The history of falling off the sidewalk, which is less than a foot off the ground, would not cause the extensive subgaleal haematoma present in this child. Furthermore, her physical examination revealed multiple bruises on her body. Blood investigations including a complete blood count and liver and pancreatic enzymes were done. A skeletal survey was not needed due to her age greater than 2 years. A head MRI scan was done which was normal. In this child, the subgaleal haematoma resolved with conservative management and did not require surgical intervention.

Children are often nervous when brought for medical care for a variety of reasons. In this case, the many new people and frightening nature of the emergency department environment could easily make the child mute. In addition, the presence of the potential offending parent, who may have threatened the child with physical violence if she spoke, could also frighten the child into not speaking. Steps can be taken to make the environment more child-friendly, and child life therapists can assist in making the medical evaluation less frightening for the child. Over time, the child may feel comfortable to disclose what occurred, which is more likely in the absence of an offending parent.