DISEASE &
TREATMENTS
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Head Trauma inchildren
Trauma is the second leading cause of death in children lessthan 15 years of age and head injury is responsible for 20% of these deaths.The outcome in the children depends on the severity of the injury as well as management.Children have a large number of productive years ahead - it is imperative thatthese children require utmost care and attention. The mechanism of injury inchildren is distinct from adults with common causes being falls (35%),recreational activities (29%) and traffic accidents (24%). There is also age specific variation withchild abuse seen frequently in children less than 2 years of age. Falls are a major cause of head injury inchildren less than 3 years. Road traffic accidents account for larger numbers asthe age of the child increases.
Children as mini adults and treat them similarly. The immatureskull has different mechanical properties and the child’s brain is undergoingmaturation and development and. Thenewborn’s skull has pliable thin bones which can significantly deform.Thepliability of the skull makes it more vulnerable to injury especially diffuseinjury. The child’s brain is much larger in proportion to the body as comparedto adults - the newborn’s brainconstitutes 15% of body weight compared to 3% in the adult. The relatively larger size of the brain of achild in comparison to the body makes it more vulnerable to injury.
Head injury could be primary or secondary. The primaryinjury is the immediate Contact forces may result in fractures, localizedcontusions and hematoma ,hemorrhages and diffuse injury. Secondary injuryresults from an array of reactive events which follow the primary event and canworsen the initial injury or cause new injury to brain. These events include hypoxia, hypotension,metabolic alterations, fluid and electrolyte imbalance, brain edema, seizures,local and systemic infections etc The secondary injury are preventable and thisconstitutes an important aim in the management of the head injured child. Variouspathologies may be seen in head injured patients.
Contusions
The Contusions may be at the site of impact[coup], counter coup. Contusions associated with tears in thecortical surface are called lacerations Concussion is a clinical syndrome characterized by a transient and reversible impairmentof consciousness which does not leave any residual deficit. Rotational forces are responsible for causinga Diffuse Axonal Injury characterizedby stretch and shearing injury to the axons and the myelin sheath at the greywhite matter junction, in the corpus callosum, dorsolateral pons and superiorcerebellar peduncle. Head injury couldalso be classified as mild, moderate or severe based on the Glasgow Coma Scale (GCS) of 13 to 15, 9to 12 and 3 to 8 respectively. Inchildren mild injuries account for 80% of all head injuries whereas moderateand severe injuries constitute 10% each. Radiological assessment includes Skull X-Rays and CT scan.
Except for a few children, most children with mildhead injury make remarkable recoveries and full recovery is the norm. The majorconcern in these patients is parental anxiety and overprotection. The overallfocus of care in moderate and severe head injuries would be to prevent brainischemia by controlling ICP and removing focal symptomatic mass lesions.
Skull Fractures:
Skull fractures are common in children with the vastmajority being linear skull fractures. The parietal bone is the most common site and patients present with painand swelling. Subgaleal andsubperiosteal hematomas may occur with the fracture and in neonates and infantsmay be substantial enough to require blood transfusion. Depressed fractures may require surgery ifassociated with a dural tear or if compound or if large underlying contusion /hematoma. There is no evidence thatelevation of a simple depressed fracture would improve neurological outcome orprevent seizures Compound depressed fractures should be explored because ofconcerns of infection. Depressedfractures in frontal area may need to be elevated for cosmetic purposes.Infants are prone to Ping-pong fracture.
Mass Lesion:
Intracranial hematoma are serious pathology and requireurgent attention. Extradural hematomas are fairly uncommon in children because thedura is tightly adherent to the periosteum. Also the groove of the middle meningeal artery is shallow and thereforethe artery is less prone to tear with injury. Almost all extradural hematomas are associated with a fracture. Subduralhematoma are second common and may be associated with rotational forces andassoacited brain injury. Intracerebralhematomas and contusions occur with increasing frequency with increasingageand occur as a result of acceleration – deceleration injury. Management of these mass lesions would dependupon the clinical condition of the child and the size of the lesions.
Growing Skull Fractures:
This is an uncommon condition found in very young childrenwith a growing brain. Also known as Leptomeningeal Cyst and Craniocerebral Erosion.It happens when there is fracture with adural tear and an outward driving force such as a growing brain, a cyst orhydrocephalus. The pulsations of thebrain against the bone edges and the pressure exerted result in erosion of thebone edge and subsequent eversion. The underlying brain gets attached to thedura an This results in the development of and prevents from fracture fromhealing.Epileptic focus often with intractable seizures and also of progressiveneurological deficit. All such casesneed surgery as the fractures never heal and the clinical and pathologicchanges are progressive
Non Accidental Injury:
Non accidental injury is injury deliberately inflicted onthe child. Also know ‘Shaken Baby syndrome’. This resulted from a relatively large infanthead pivoting back and forth on the cervical spine They are brought to thehospital either with non specific complaints like lethargy, irritability,unresponsiveness or even apnea or with a history of a minor injury - usuallyfall from short height. Also associated with soft tissue and skeletal injury indifferent stages of healing. Fracturesare bilateral, multiple or stellate. Retinal hemorrhages occur in 65 – 95% .The outcome of such injuries depends upon the condition of the child onpresentation.
Birth Injuries:
Birth injuries could be due to mechanical forcesduring childbirth or could result from hypoxic / ischemic insults. Themechanical forces could result in scalp injuries, fractures or intracranialhematoma. Scalp injuries in the newborn could be of three types – Caput Succedaneum, Subgaleal hematoma and Cephalhematoma. Caput is seen in almost all children andinvolves edema of the outer layers of the scalp. It usually resolves in a dayor two. Subgaleal hematoma is rare butpotentially life threatening because the large subgaleal space can accommodatethe whole blood volume of a neonate. The cephalhematoma is underneath theperiosteum and is limited by the cranial sutures.
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