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Child Head and Facial Injuries

Child Head and Facial Injuries

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Published by Surgicalgown
Section I – Head injuries


Introduction


Injuries to the brain and spinal cord are a major cause of morbidity and mortality in children. The Traumatic Brain Injury Project estimates that over one million children in the USA suffer some form of head injury per year. While the majority of these will be mild injuries, over 30 000 will suffer permanent disability. Spinal cord injury is less common in this age group affecting around 1500 children in the US per year (about 14% of all spinal cord injuries). The emotional, financial and social burdens placed on the family and the community as a whole are enormous.


The principles of managing head and spinal cord injuries in children are essentially the same as those for adults. However, because of the physiological differences between these two populations, and even within the paediatric population itself, there are differences in the epidemiology, the presentation and the complications that arise from head injury. It is these differences that are discussed here.


Aetiology


Overall, motor vehicle accidents account for the majority of head injuries in children (Chan and Walker 1989). In children under two years old, however, falls are the most significant cause of head injury. (Greenes and Schutzman 1997; Lavelle and Shaw 1998). These are often from low heights such as off beds and from change tables. Falls from greater heights are increasingly common as children learn to climb. Non-accidental injury is a cause of major head injury in this younger age group. In later childhood, pedestrian and bicycle accidents are also common causes of major injury. In adolescence suicide is an increasingly important cause, particularly in boys.


Motor vehicle accidents are also the major cause of spinal injuries. However, in the paediatric population, one third occur during play or sporting events. Diving into a shallow pool is a well known cause of recreational accidents.


Key points


Motor vehicle accidents and falls are the most common causes of head and spinal cord injuries in children.

Anatomy and biomechanics


In the neonate, the head is proportionately larger than in the adult, with underdeveloped neck muscles for its support. Despite this, it must accommodate considerable growth of the brain. The bone plates that make up the skull are not yet fused at the sutures. Thus, the volume of the skull is capable of increasing in size not only from increase in brain mass, but from and increase in any compartment of its contents. Because of this, an intracranial haemorrhage may reach considerable size before causing neurological symptoms.


The brain itself is still not fully developed. Myelinisation of the brain is underway but far from complete, contributing to the lower fat and higher water contents of the neonatal brain. At this stage, both cerebral blood flow and metabolism are lower than in the adult.


With development of the brain, myelinisation progresses to adult development by the age of four years. The cranial sutures fuse on average by 18months old, though may still be patent at three years. Cerebral blood flow and metabolism increase and surpass adult levels by three years old decreasing only in adolescence. By adolescence, the mechanics of the skull and brain are those of the adult.


Presentation


It is important to get a thorough history of events when a child has suffered a head injury particularly as the child can often not give one themselves. The velocity of the injury (high vs low speed), the height fallen and the structure of the floor (carpet vs stone), event preceding and following (e.g. seizures), are all important in determining the possible severity of the injury.


As thorough a neurological examination as is possible given the age of the child, should be performed. This should include palpation of the scalp for boggy swellings, palpation of the fontanel, measurement of head circumference for a baseline readi
Section I – Head injuries


Introduction


Injuries to the brain and spinal cord are a major cause of morbidity and mortality in children. The Traumatic Brain Injury Project estimates that over one million children in the USA suffer some form of head injury per year. While the majority of these will be mild injuries, over 30 000 will suffer permanent disability. Spinal cord injury is less common in this age group affecting around 1500 children in the US per year (about 14% of all spinal cord injuries). The emotional, financial and social burdens placed on the family and the community as a whole are enormous.


The principles of managing head and spinal cord injuries in children are essentially the same as those for adults. However, because of the physiological differences between these two populations, and even within the paediatric population itself, there are differences in the epidemiology, the presentation and the complications that arise from head injury. It is these differences that are discussed here.


Aetiology


Overall, motor vehicle accidents account for the majority of head injuries in children (Chan and Walker 1989). In children under two years old, however, falls are the most significant cause of head injury. (Greenes and Schutzman 1997; Lavelle and Shaw 1998). These are often from low heights such as off beds and from change tables. Falls from greater heights are increasingly common as children learn to climb. Non-accidental injury is a cause of major head injury in this younger age group. In later childhood, pedestrian and bicycle accidents are also common causes of major injury. In adolescence suicide is an increasingly important cause, particularly in boys.


Motor vehicle accidents are also the major cause of spinal injuries. However, in the paediatric population, one third occur during play or sporting events. Diving into a shallow pool is a well known cause of recreational accidents.


Key points


Motor vehicle accidents and falls are the most common causes of head and spinal cord injuries in children.

Anatomy and biomechanics


In the neonate, the head is proportionately larger than in the adult, with underdeveloped neck muscles for its support. Despite this, it must accommodate considerable growth of the brain. The bone plates that make up the skull are not yet fused at the sutures. Thus, the volume of the skull is capable of increasing in size not only from increase in brain mass, but from and increase in any compartment of its contents. Because of this, an intracranial haemorrhage may reach considerable size before causing neurological symptoms.


The brain itself is still not fully developed. Myelinisation of the brain is underway but far from complete, contributing to the lower fat and higher water contents of the neonatal brain. At this stage, both cerebral blood flow and metabolism are lower than in the adult.


With development of the brain, myelinisation progresses to adult development by the age of four years. The cranial sutures fuse on average by 18months old, though may still be patent at three years. Cerebral blood flow and metabolism increase and surpass adult levels by three years old decreasing only in adolescence. By adolescence, the mechanics of the skull and brain are those of the adult.


Presentation


It is important to get a thorough history of events when a child has suffered a head injury particularly as the child can often not give one themselves. The velocity of the injury (high vs low speed), the height fallen and the structure of the floor (carpet vs stone), event preceding and following (e.g. seizures), are all important in determining the possible severity of the injury.


As thorough a neurological examination as is possible given the age of the child, should be performed. This should include palpation of the scalp for boggy swellings, palpation of the fontanel, measurement of head circumference for a baseline readi

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Published by: Surgicalgown on Jun 10, 2009
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Section I – Head injuries
Introduction
Injuries to the brain and spinal cord are a major cause of morbidity and mortality in children. The TraumaticBrain Injury Project estimates that over one million children in the USA suffer some form of head injury per year. While the majority of these will be mild injuries, over 30 000 will suffer permanent disability. Spinalcord injury is less common in this age group affecting around 1500 children in the US per year (about 14%of all spinal cord injuries). The emotional, financial and social burdens placed on the family and thecommunity as a whole are enormous. The principles of managing head and spinal cord injuries in children are essentially the same as those for adults. However, because of the physiological differences between these two populations, and even withinthe paediatric population itself, there are differences in the epidemiology, the presentation and thecomplications that arise from head injury. It is these differences that are discussed here.
Aetiology
Overall, motor vehicle accidents account for the majority of head injuries in children (Chan and Walker 1989). In children under two years old, however, falls are the most significant cause of head injury.(Greenes and Schutzman 1997; Lavelle and Shaw 1998). These are often from low heights such as off beds and from change tables. Falls from greater heights are increasingly common as children learn toclimb. Non-accidental injury is a cause of major head injury in this younger age group. In later childhood,pedestrian and bicycle accidents are also common causes of major injury. In adolescence suicide is anincreasingly important cause, particularly in boys. Motor vehicle accidents are also the major cause of spinal injuries. However, in the paediatric population,one third occur during play or sporting events. Diving into a shallow pool is a well known cause of recreational accidents.
Key points
Motor vehicle accidents and falls are the most common causes of head and spinal cord injuries inchildren.
Anatomy and biomechanics
In the neonate, the head is proportionately larger than in the adult, with underdeveloped neck muscles for its support. Despite this, it must accommodate considerable growth of the brain. The bone plates thatmake up the skull are not yet fused at the sutures. Thus, the volume of the skull is capable of increasing insize not only from increase in brain mass, but from and increase in any compartment of its contents.Because of this, an intracranial haemorrhage may reach considerable size before causing neurologicalsymptoms.The brain itself is still not fully developed. Myelinisation of the brain is underway but far from complete,
 
contributing to the lower fat and higher water contents of the neonatal brain. At this stage, both cerebralblood flow and metabolism are lower than in the adult.With development of the brain, myelinisation progresses to adult development by the age of four years.The cranial sutures fuse on average by 18months old, though may still be patent at three years. Cerebralblood flow and metabolism increase and surpass adult levels by three years old decreasing only inadolescence. By adolescence, the mechanics of the skull and brain are those of the adult.
Presentation
It is important to get a thorough history of events when a child has suffered a head injury particularly as thechild can often not give one themselves. The velocity of the injury (high vs low speed), the height fallenand the structure of the floor (carpet vs stone), event preceding and following (e.g. seizures), are allimportant in determining the possible severity of the injury.As thorough a neurological examination as is possible given the age of the child, should be performed.This should include palpation of the scalp for boggy swellings, palpation of the fontanel, measurement of head circumference for a baseline reading and fundoscopic examination. When the neurologicalexamination is normal and there are no outward signs of obvious trauma, and in the face of minor traumasuch as a fall from a low height, the risk of intracranial injury may be low and the need for further investigation may be obviated (Fisher 1997; Strouse et al. 1998; Gruskin and Schutzman 1999). However,in the patients younger than 12 months, the absence of any outward signs of injury may be illusory. Up to20% of intracranial injury may be occult in this age group (Greenes and Schutzman 1998). When investigating suspected spinal cord injury, the examination should be aimed at determining the levelof injury. Myotomal, dermatomal and reflex changes may be used to assess the the level of injury in thecord. This is particularly important as there may be no radiological findings to support the diagnosis.Some clinical patterns are common in the presentation of pediatric head injury. The "pediatric concussionsyndrome" occurs in about 10% of all admissions. It consists of pallor, drowsiness and vomiting and maypresent some hours or even days after the injury. It usually causes concern regarding intracranial injury. Inthe infant, presentation may be vague. Drowsiness, poor feeding and vomiting should make onesuspicious if there is no good history of trauma.Seizures are a common presentation with head injury occurring in up to 30% of children with head injuries(Bruce 1995). Unlike in adults, early seizures are not a predictor of ongoing epilepsy, and if they settle, donot require ongoing management.Coma scores, modified to suit the paediatric population, can be used to gauge the severity of the injury atpresentation and to monitor the course of illness. It must be kept in mind, however, that the score isdependent on the child's development. For example, the neonate can score a maximum of nine on thePediatric Glasgow Coma Scale, with spontaneous eye opening (4), crying (2) and flexion to painful
 
stimulus (3) (Simpson 1997).Certain findings should alert the doctor to child abuse. A vague history, such as that of an unwitnessed fallor variation in the story, plus signs of significant trauma, such as a scalp haematoma and retinalhaemorrhages on fundoscopy, are highly suggestive of a non-accidental injury and follow up is required(Bruce 1992).
Key points
A thorough history and examination are vital.
Myotomal, dermatomal and reflex changes may give clues to the level of spinal cord injuries.
Be alert to non-accidental injuries.
Classification of injuries
In older children, the patterns of injury are similar to those seen in adults. In young children (< 2 years of age) the patterns of injury are not.Birth injuriesBirth injuries account for less than 3 % of all head injury admissions in children (Bruce 1995). The actualincidence of head injury at birth is unknown, thought it has declined significantly with improved obstetricpractices and with the increase of caesarean section. A higher incidence of birth injuries is seen inprimiparous births, precipitous labour, breach delivery and forceps delivery (Harpold et al. 1998). A varietyof injuries are seen, the majority of which can be managed conservatively.These are listed in Table 28.1.Spinal cord injuries are uncommon in this age group.Injuries in the infant.Skull fracture is particularly common in this age group. Both linear and depressed fractures occur. Theformer is important for its risk of producing a "growing" skull fracture. The latter is important for its cosmeticeffect and slightly higher incidence of associated intracranial injury.Intracranial injuries are less common in this age group. However, when present they are often associatedskull and scalp injuries. Intracranial injuries are often associated with more severe injuries. Extraduralhaematomas are usually located higher in the parietal area than those seen in adults. These may occur after a seemingly trivial accident, and in 85% there is no history of a loss of consiousness (McLaurin1982). Acute subdural haematomas are less common than in adults. They are relatively common in childabuse, and if not detected early, may progress to become chronic. Chronic subdural haematomas arerelatively common in infancy. In these instances, there may be no obvious history of head injury. Thepresentation may be vague. McLaurin states that subdural haematomas are more likely to be acute incases of child abuse.

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