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Diagnosing Depressed Skull Fracture in a Young Child

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Diagnosing Depressed Skull Fracture in a Young Child Nursing Practice Keywords: Skull fracture/Children/ Neurology Case study Neurology Skull fractures associated with intracranial injury are a leading cause of traumatic death in childhood. Children with head injuries should be monitored for signs of deterioration Diagnosing depressed skull fracture in a young child respiratory rate 32/min and oxygen satura- In this article... tion 97% in air. He was drowsy but easily Risks associated with head injury and skull fracture roused by his parents. The Glasgow Coma Scale score was 12/15, which could indicate The importance of monitoring and early diagnosis an intracranial injury and raised intracra- nial pressure. A neurological examination revealed Authors Shameem Ahmed is assistant left-sided hemi-paresis indicative of raised professor in neurosurgery; Rupa Thenseen intracranial pressure. A right-sided lateral Frank is sister in charge, neurosurgical soft tissue swelling and haematoma along operation theatre; both at Gauhati Medical with a depression of the underlying bones College, Guwahati, India; Siba Prosad Paul was noted on palpation of his skull. is specialty trainee in neonates at South- He was reviewed by an anaesthetist and mead Hospital, Bristol his condition was considered to be stable. An urgent non-contrast computed tomog- ead injury is the most common raphy scan revealed a large depressed frac- cause of death and disability in ture (>5mm) involving the right fronto- people aged below 40 years parieto-occipital bone (Fig 1). The boy was H(National Institute for Health Fig 1. Large right fronto-parieto-occipital reviewed by the neurosurgical team and an and Care Excellence, 2014). It accounts for bone simple depressed fracture exploration and elevation of the depressed 1.4 million attendances at accident and fragment was carried out on the same day. emergency departments in England and leading cause of traumatic death in child- He was admitted to the high depend- Wales a year, of which 200,000 people are hood (Caviness, 2014). ency unit in the neurosurgical ward for admitted to hospital (NICE, 2014). Between Skull fractures are traditionally classified regular observations of vital parameters, 33-50% of attendances are in children aged as linear, depressed or open (Caviness, 2014). neurological status with paediatric GCS less than 15 years (NICE, 2014). It is esti- Depressed skull fractures result from a scoring and meticulous management of mated that one in five patients admitted significant force. It is estimated that 30% of fluid balance and intravenous antibiotics. with a head injury has features suggestive depressed skull fractures in children have The boy improved, his hemiparesis of a skull fracture or have evidence of brain associated intracranial injuries. In addition resolved within 24 hours of surgery and he damage (NICE 2014). to intracranial haemorrhage, complica- started mobilising the next day. He was The incidence of skull fractures in chil- tions such as compression of underlying discharged home on the third post-opera- dren presenting with head injury in acci- brain parenchyma, intraparenchymal bone tive day with advice on safety issues at dent and emergency units in the US ranges fragments and cosmetic deformity are also home and in the playground. from 2% to 20% and intracranial injury seen. Signs and symptoms of depressed He was referred to paediatric services associated with skull fractures is the skull fractures are outlined in Box 1. and six months after the injury is reported All depressed skull fractures in children to be progressing well. should be discussed and managed in con- BOX 1. FractURE SIGNS sultation with a neurosurgeon as surgical Conclusions elevation of the depressed fragment may This case illustrates the importance of Signs of open or depressed skull fracture be needed (Caviness, 2014). being aware of depressed skull fractures in or penetrating head injury In children with open skull fractures it children. A trained member of staff should ● Clear fluid running from the ears or is important to consider intravenous anti- assess all patients within 15 minutes of nose biotics and pneumococcal vaccination as arrival at hospital with a head injury ● Black eye with no associated damage they are at a high risk of developing pneu- (NICE, 2014). NT around the eyes mococcal meningitis (Caviness, 2014). ● Bleeding from one or both ears and/ References Caviness AC (2014) Skull Fractures in Children. www. or bruising behind one or both ears Case study uptodate.com/contents/skull-fractures-in-children ● Penetrating injury signs A one-year-old boy was brought to the National Institute for Health and Care Excellence ● Visible trauma to the scalp or skull emergency unit after being hit acciden- (2014) Head Injury – Triage, Assessment, Investigation and Early Management of Head Injury Source: NICE (2014) tally by a brick on the right side of his head. in Children, Young People and Adults. www.nice. On arrival, his heart rate was 146/min, org.uk/cg176 20 Nursing Times 18.02.15/ Vol 111 No 8 / www.nursingtimes.net.
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