Case 94

A 6-month-old girl was brought to your office with a history of falling off the bed after her mother left the room. The child was able to roll and crawl and was found on the carpeted floor next to the bed after her mother heard her cry. There was no loss of consciousness. Her mother thought she was fine during the day since she acted normally, ate well and slept well overnight. The next morning, her mother noticed swelling over her forehead (Image 94a) which had become progressively worse over the day. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig94a.jpg"/>

What does Image 94a show?

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

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The child had bilateral swelling over the frontal bones without palpable fracture. No significant bruising was appreciated and the child appeared neurologically normal. A head magnetic resonance imaging scan was done (Image 94b) which showed the location of blood as being subperiosteal. These were thought to be traumatic cephalohaematomas consistent with a history of short fall. The imaging differentiated the location of bleeding from intracranial or subgaleal locations. While unusual, isolated and delayed extra-axial bleeding has been described from minor falls without overlying skin bruising or skull fracture. ¹

Given the possibility of inflicted trauma in this presentation, full imaging of the axial skeleton using a skeletal survey was indicated. Coagulation tests such as a complete blood count, prothrombin time and partial thromboplastin times were also indicated to determine if the child had an underlying coagulation disorder contributing to the bleeding.