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 reading and fundoscopic examination. When the neurological examination is normal and there are no outward signs of obvious trauma, and in the face of minor trauma such 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 to 20% 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 level of injury. Myotomal, dermatomal and reflex changes may be used to assess the the level of injury in the cord. 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 concussion syndrome" occurs in about 10% of all admissions. It consists of pallor, drowsiness and vomiting and may present some hours or even days after the injury. It usually causes concern regarding intracranial injury. In the infant, presentation may be vague. Drowsiness, poor feeding and vomiting should make one suspicious 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, do not require ongoing management. Coma scores, modified to suit the paediatric population, can be used to gauge the severity of the injury at presentation and to monitor the course of illness. It must be kept in mind, however, that the score is dependent on the child's development. For example, the neonate can score a maximum of nine on the Pediatric 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 fall or variation in the story, plus signs of significant trauma, such as a scalp haematoma and retinal haemorrhages 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 injuries Birth injuries account for less than 3 % of all head injury admissions in children (Bruce 1995). The actual incidence of head injury at birth is unknown, thought it has declined significantly with improved obstetric practices and with the increase of caesarean section. A higher incidence of birth injuries is seen in primiparous births, precipitous labour, breach delivery and forceps delivery (Harpold et al. 1998). A variety of 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. The former is important for its risk of producing a "growing" skull fracture. The latter is important for its cosmetic effect and slightly higher incidence of associated intracranial injury. Intracranial injuries are less common in this age group. However, when present they are often associated skull and scalp injuries. Intracranial injuries are often associated with more severe injuries. Extradural haematomas 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 (McLaurin 1982). Acute subdural haematomas are less common than in adults. They are relatively common in child abuse, and if not detected early, may progress to become chronic. Chronic subdural haematomas are relatively common in infancy. In these instances, there may be no obvious history of head injury. The presentation may be vague. McLaurin states that subdural haematomas are more likely to be acute in cases of child abuse.

Injuries in the child and adolescent. Once the sutures are closed, the mechanism and pathology of head injury more closely resemble those of adults. As with infants, intracerebral collections are associated with more severe head injuries. Diagnosis In assessing children with head injury, two questions need to be answered. Firstly, the severity of the injury may be difficult to assess, and the vomiting and drowsy child who looks as though they have a mass lesion may simply require observation. Secondly, the question of abuse may arise. Radiological assessment is important in answering these questions. Lastly, children at risk for later complications should be identified such that appropriate follow up can be organised. Skull x-rays The use of skull x-rays in controversial in assessing head injuries. In older children, as with adults, skull xrays rarely add more information than has already been gleaned by a good neurological examination and is thus unnecessary (Grasso and Keller 1998). However, skull fractures are particularly common in children less than one year of age, even in the face of minor trauma (Bruce 1995). Further, it is this age group which is at risk for developing the "growing" skull fracture, which may lead to delayed cortical damage and epilepsy. Thus in infants, skull x-rays are useful in identifying those patients at risk of delayed complications. Cervical spine x-rays As with adults, the lateral cervical spine x-ray is important in assessing the trauma victim. However, one to two thirds of children presenting with a cord injury may have no radiological signs supportive of the diagnosis. This entity is named spinal cord injury without radiological abnormality, or SCIWORA (Pang and Wilberger 1982). Thus, the absence of x-ray evidence does not rule out cord injury. CT scanning. CT is the imaging procedure of choice to investigate head injury in major centres. It is used to determine the presence of intracranial trauma, and sometimes to better delineate a fracture (e.g. depressed skull fractures). A CT scan should be performed in any child with a depressed level of consciousness or other firm neurological signs after a head injury. In the alert child without neurological signs, a CT can be avoided (Fisher 1997). Some CT findings may alert the doctor to child abuse. Subarachnoid haemorrhage associated with a posteriorly placed interfalcine acute subdural haematoma and basal ganglia oedema are all more common in abused children than in those suffering accidents (Bruce 1995; Hymel et al. 1997).

MRI

As with adults, MRI is rarely used in the acute setting. However, it may be useful for assessing children in whom a non-accidental head injury is suspected. It is also useful in the assessment of children with spinal cord injuries. MRI may reveal ligamentous damage, compression of the cord by soft tissue or damage to the spinal cord itself. It is especially useful in the ongoing assessment of the child with SCIWORA (Grabb and Albright 1996).

Special note: Investigating the child-at-risk. One of the most difficult issues in dealing with head injury in childhood is the issue of child abuse. Identification of these children is important in preventing further injury to the child, and to minimise the effects of the injuries which are often severe and warrant aggressive management. As noted above, the doctor may be alerted to the possibility of child abuse during the initial history and examination. These include: a vague and inconsistent history, outward signs of signficant head injury and the presence of retinal haemorrhages on fundoscopy (Bruce 1995). In these children, the clinical findings may be out of proportion to the history given. This may be supported by radiological evidence of severe head trauma. Common radiological findings include the presence of intracranial haemorrhages of varying age (chronic subdurals mixed with acute), acute subarachnoid haemorrhage in association with a posterior interhemispheric acute subdural, the presence of intracerebral hypodensities such has basal ganglia oedema (Bruce 1995; Hymel et al. 1997; Dias et al. 1998). Radiological investigation should also include a full skeletal survey to identify other injuries. An urgent referral to the appropriate investigators is warranted. The clinical and radiological findings suggestive of child abuse are listed in Table 28.2

Management The principles of management are the same as those for adults. Acute trauma assessment following the well known "ABC" rules should be followed. Secondary brain injury is as injurious in this age group, if not more, than in adults and thus hypoxia and hypotension should be aggressively avoided. Children suffering minor head injuries without signs of neurological damage may be managed at home after a short period of observation in hospital. This includes infants with skull fractures in whom abuse is not suspected. Any alteration in the level of consciousness or other signs of neurological injury warrants further observation and investigation. Surgery is indicated in few situations. These include:

a) Elevation of a depressed skull fracture. This should be performed when there is a significant (> 0.5 cm) depression, where there are signs of dural laceration such as intracranial air, and when the injury has occurred in a cosmetically obvious location. Some fractures can be managed conservatively, particular in infants in whom skull growth may naturally remodel the fracture with time. b) Evacuation of an intracranial haemorrhage. This most commonly involves the evacuation of an extradural haematoma. Acute subdural haematomas are rare. c) Intracranial pressure monitoring. This is imperative in the child with a head injury severe enough to warrant intubation and management in an intensive care unit. It allows aggressive cerebral perfusion pressure management, and is also important in the detection of malignant intracranial hypertension (see below) which may occur hours to days after the initial injury. Complications Malignant intracranial hypertension. This is an early complication which is more common in children and may occur after significant head injury, even though apparently mild. It is associated with both subarachnoid and subdural haemorrhage. It cause is unknown, although increased cerebrovascular reactivity compared with adults is the favoured theory (Bruce 1981). It may occur from 12 hours to several days after the injury. Aggressive ICP management is required, and in desperate circumstances, bifrontal decompressive craniectomy may be performed, a procedure which has a greater success rate in children than in adults (Polin et al. 1997). Nevertheless, the usefulness of such a drastic surgical measure remains controversial. Growing skull fractures This unusual complication is virtually unique to small children of less than three years of age. It presents as a swelling of the scalp or as a rapid increase in the child's head circumference. Often asymptomatic, seizures and signs of cortical dysfunction such as hemiparesis, may occur. These lesions occur at sites of a previous linear skull fracture with an underlying dural tear of similar orientation to the fracture. Herniation of brain through the defect which progressively enlarges is the cause of the resulting defect (Tomita 1996). Management is surgical, with excision of gliotic brain tissue and repair of the dural defect. Because this is a disorder of infancy, cranioplasty, though an option, is not necessary, as new bone growth often results in complete Epilepsy

As with adults, late seizures requiring medical control, are a complication of pediatric head injury. Lundar and Nestvold (1985) noted a 7% incidence of late seizure within 5 years of head injury caused by traffic accidents. Given that these include more severe injuries, the overall incidence is probably somewhat less. Unlike in adults, however, the occurrence of early seizures is not a predictor for later ones (Jennet 1997). CSF leak These commonly occur after a base of skull fracture in which the overlying dura is disrupted. The main risk of CSF leak is meningitis. Thus it is important to identify and to manage. Watery fluid running from the nose or the ear after a head injury is the main sign of a leak. In general, management is initially conservative, with bed rest, and head elevation. The use of antibiotics is controversial in this setting. Where there is no resolution, management involves localising the leak if possible, using metrizamide cisternography. Lumbar drainage may help to settle the leak. If not, and rarely, open craniotomy and repair of the dural defect must be done (Milhorat 1978).

Section II - Maxillofacial injuries

Introduction Maxillofacial injuries are extremely common in children but fortunately most are minor injuries and due to falls and sport. Severe maxillofacial injuries are less common and seen mainly in car impacts with pedestrians. Minor injuries Mechanisms of injury Falls are the most common mechanism of injury and cuts to the chin, lips and tongue are the most frequent injured parts. The history of the mechanism of injury is the most important aspect of early management. If the physician is happy that the injury was a result of a very small force then he should be confident to treat it as an isolated injury and not concern himself that there may be other injuries. In such situations of a single system injury there are rarely other significant problems which would put at risk the child’s life. In this situation the injury should be treated on its merits. Treatment of lacerations It is often difficult to decide whether to suture under local or general anaesthesia. There is subtle pressure of simple logistics and cost reduction to suture under local anaesthetic. Every child is different and the clinician should discuss the options with the parents and the child. However, where there is doubt from the point of view of cosmetic result or the cooperation of the child, it is best to perform the procedure under general anaesthesia. Many children develop a phobia of hospitals that relate back to an unpleasant

suturing experience. A timeless question is: how would you like your child treated? Chin lacerations can be treated by the use of glues or steri strips, or simple suturing under local anaesthetics. The wounds heal well with a good cosmetic result. Other facial and scalp lacerations are often deep and the tissues can be painful to infiltrate with local anaesthetic. Also, seeing the needle come close to their eyes frighten the child. Overall, unless the child is co-operative, general anaesthetic is preferred. Lip lacerations require assessment as to whether the wound crosses the vermilion margin. Should this occur then it is important to get accurate apposition, as the cosmetic result can be unsatisfactory if the edges are not closely opposed. In such situations the use of general anaesthetic or nitric oxide is warranted so the child is kept still and the sutures can be placed with great accuracy. Sutures inside the mouth should be of chromic catgut and the knots buried to prevent the children chewing them out. Lacerations to the tongue are often treated by just giving the child mouthwashes and watching it heal. However steps of over 1 cm or untidy edges hanging free need to be sutured with chromic catgut with the knots buried. Dog bites Dog bites to the face are an extremely dangerous injury in that the deep structures can be damaged and there is a high risk of infection. The child should be taken to theatre and the wounds cleaned meticulously to remove any foreign body. The wound should be washed out with copious amounts of normal saline and the edges freshened up. Any devitalised tissue should be removed. In most instances it is possible to perform primary anastomosis with this regime. A mistake made in dog bites is to clean the wound in the emergency department and place sutures. Such treatment will almost certainly result in a secondary infection. The child that has been bitten by a dog has usually sustained some psychological trauma and the child needs to be assessed regularly by the local doctor. Prevention is the important part in the management of dog bites in children. Very young children and dogs do not mix and they need to be supervised at all times. While there are dangerous breeds of dogs, which should be outlawed in urban communities, any dog can bite and children always need close supervision. A common problem is a child going to a neighbour’s house with the parents being unaware that there is a dog within the environment. Moderate injuries These are commonly occur from falls from moving bikes, falls from a height of 1-2 metres during play and kicks from horses. In these situations there has been more force and the child needs careful assessment to ensure that there are no associated injuries. Skull X-rays and CT scans are warranted as often a

neurological examination is difficult and the child is unable to co-operate. Injuries to look for are blowout fractures of the orbit and maxillary fractures and injuries to the dentition. These can be difficult to detect, as the facial bones of young are difficult to interpret. It is important to give the radiologist the maximum of clinical information to assist in interpretation of the images. Severe injuries These occur predominantly in pedestrian injuries and in crush injuries. They can also occur in unrestrained or restrained car passengers and in more severe horse kicking injuries. In these situations the child needs a full emergency assessment with particular attention to airway and breathing management. Children, as in adults, can suffer immense haemorrhage from the base of skull and from maxillofacial fractures. In the first instance attainment of an adequate airway is most important. In most instances an endotracheal tube can be placed. But if the situation demands, a tracheostomy can be performed. As in adults the best way of reducing ongoing haemorrhage is to reduce the fractures. n severe pedestrian injuries there is almost always an associated and thoracic injuries and the patient is a complex management problem and requires a multi-disciplinary approach. Once the life threatening injuries have been managed the child needs a full cranio-facial secondary survey. Every area of the head should be inspected and then the eyes, ears and mouth examined. A common mistake, especially in the unconscious patient, is to concentrate on the prime injury such as a fractured base of skull and miss other injuries such as fractures to the mandible, nose or orbits. Child abuse It is less common than one would think for the child to be hit about the face and head. A more common child abuse injury is for the child to be shaken and present with neurological symptoms. The important feature of the examination in the child is to look for retinal haemorrhages. In some instances unusual burns around the face from cigarettes or to the ears can occur in situations of child abuse. If the history does not fit the injuries or there are more than two injuries separated in time then child abuse must be suspected. Unusual injuries In situations where there is an unusual history of injury, even the small entry wound warrants careful investigation. Often such children present with a small entry wound and an incomplete history. In such instances later evaluation shows that shot gun pellets, objects thrown by other children or objects flung by lawn mowers have been involved. If one is faced with a small penetrating wound and an incomplete history, careful physical examination, Xrays, CT scans are warranted. The child’s bony skeleton is thin and this together with the amount of cartilage allows significant penetrations of flying objects.

Paediatric features of emergency treatment Airway The assessment of this is similar to an adult. Features particular to children are the provision of the best airway by placing the child in the sniffing position. Clinicians need to be cautious not to produce trauma with an oral airway. In an adult the oral airway can be inserted upside down and then rotated 1800. But in a child this manoeuvre may damage the mouth or pharynx. A careful check needs to be made of teeth, especially with the onset of secondary dentition. The primary teeth can be loose and easily dislodged even with minor trauma. A missing tooth should be sought at the scene and if there is no clear indication as to the whereabouts of the tooth an X-ray should be performed. Teeth can be aspirated into airways and in these situations can be extremely difficult to remove. A skilled endoscopist with appropriate grasping forceps is required. If there is considerable haemorrhage a sucker should be used and if the airway is still inadequate, intubation should be performed. If this proves impossible tracheostomy may be necessary.

Breathing Children who have severe maxillofacial trauma usually have other system injuries and a careful assessment needs to be made for the presence of an associated pneumothorax (see chest section). Circulation Children can exsanginate from serious maxillofacial trauma. The same process of manual reduction of the injury applies as it does in adults. If the child has severe maxillofacial trauma the child is best taken to the operating theatre and anaesthetised. In this situation the operation theatre acts as the intensive care environment whereby manual reduction, followed by packing, followed by operative procedures can be readily and sequentially instituted. Unfortunately in the situation of severe maxillofacial trauma there is not sufficient time for investigative tests. The same principle as to other trauma management applies in that if the child is unstable is best treated for and managed in theatre. Tests should only be undertaken when the child remains stable for a half-hour period after a half blood volume resuscitation. Specific injuries Eyelid These need expert assessment as the injuries are often deeper than might appear. Eye One third (33%) of severe eye injuries are in children, although only 8% of eye injuries occur in children. Sometimes the history is misleading as the child may deny there was a prohibited activity (playing with sticks, scissors, arrows or pellet guns). Therefore the initial examining clinician needs a high index of suspicion, and where in doubt refer to a specialist paediatric eye clinic. It is far better to over-refer than

miss a treatable eye injury. Fractured nose The nose is the facial bone most commonly fractured. It is often overlooked and results in later deformity. As a general policy: any child with an injury sufficient to cause a “bloody nose” or result in bruising or persisting pain needs a careful nasal examination. The septum should be midline without irregularity. If the septal mucosa has a bluish bulge; this may be a haematoma. The patient should be referred as fractures will need reduction and haematomas may need drainage. Mandibular fractures These are important in children as fractures may involve growth plates and involve secondary teeth. Radiology can miss subtle fractures but careful examination for malocclusion and painful points will reveal most fractures.

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