Volume 5, Case 10
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
This is a 7 month old female who presents to the emergency department with a chief complaint of a growing lump on the side of her head. A cousin who was baby sitting the infant six days ago had placed her on a couch. The infant fell off the couch. The infant's grandmother was in the home at the time. The infant cried right away. There was no loss of consciousness or drowsiness noted. Two days later (four days ago), mother noted a lump developing on the right side of the infant's head. Since then, mother has noted that the lump has become larger and the lump feels like a large soft spot in her head. There is no history of vomiting or other trauma.
Exam: VS T37.5 (rectal), P140, R36, BP 75/40, weight 5th percentile for age, height 25th percentile for age. She is alert and active in no distress. Anterior fontanelle flat. A 10 cm region of swelling is noted over the right parietal region raised about 2 to 3 cm. The swelling is soft. PERRL, red reflex present bilaterally. Fundi difficult to view. TM's no blood. Nose clear. Oral clear, moist. Neck non-tender, supple. Heart regular without murmurs. Lungs clear. Trunk without bruising. Abdomen soft, flat, bowel sounds active. No abdominal tenderness or masses. No hernias. Normal genitalia. Extremities without swelling, deformity, or bruising. Tone good. Uses all extremities well.
A skull series is obtained.
View skull series.
Clinically, this infant appears to have a subgaleal hematoma. These usually are brought to medical attention several days after sustaining an underlying skull fracture. The presentation is often not immediate since the hemorrhage from the fracture forms a tight and palpably rigid swelling under the aponeurosis of Galen. As blood from the hematoma is resorbed, the swelling softens. This "soft spot" on the infant's head is then noted by parents, often prompting a visit to a physician. In most instances, there are no complications, since several days have elapsed since the head trauma without the infant exhibiting any signs or symptoms of brain injury. Radiographs of the skull would most often not alter one's clinical approach except in a case such as this.
This skull series shows extensive fractures of the right parietal skull. One would expect to see a simple linear fracture in this region if the trauma were accidental. Additionally, there are extensive fractures over the occipital skull and the contralateral parietal skull as well. A simple fall off a couch could not possibly account for all these fractures. Child abuse is likely. A CT scan of the brain is performed.
View CT scan.
This high CT scan cut shows a bone window on the left and a brain window on the right. The open anterior fontanelle is noted at the top of the both images. The large right parietal scalp swelling (subgaleal hematoma) is noted. The bone window on the left shows a large right parietal fracture. A smaller left parietal fracture is also evident. The coronal sutures are visible. There are several lucencies in the occiput. Two of these are the lambdoidal sutures while the others are occipital fractures. The brain is normal. Lower cuts do not demonstrate cerebral hemorrhages or edema. The posterior interhemispheric subdural hematoma is not evident on the lower cuts. This finding would be indicative of shaken infant syndrome as noted on Case 1 of Volume 1.
A skeletal survey is obtained.
View skeletal survey.
No other fractures are identified on this skeletal survey. The upper extremities are not shown here. They are negative for fractures as well.
Because of the likelihood of child abuse and the potential for repeated inflicted head trauma, the infant is hospitalized and the child protective service is notified. During hospitalization, this infant does well. There is good weight gain and her neurological function and developmental evaluation are normal. A retina exam performed by an ophthalmologist is negative for hemorrhages.
On hospital day three, she is noted to be less active than she has been and she vomits three times. Abdominal examination is negative. She vomits again and is noted to be lethargic. A nasogastric tube is placed. A repeat CT scan is obtained to rule out a hemorrhage. The repeat CT scan fails to find any brain abnormalities. The skull fractures and scalp swelling are unchanged.
Develop a differential diagnosis at this point and a diagnostic plan. An IV is started. Laboratory studies are drawn and she is started on IV fluids at a moderate rate.
An abdominal series is ordered as part of her evaluation.
View abdominal series.
The supine view is on the left and the upright view is on the right. Is this abdominal series helpful? How does it affect the differential diagnosis? What should be done at this point?
This abdominal series shows a paucity of bowel gas. An NG tube is in the stomach. Is this pattern consistent with an ileus or a bowel obstruction? Using the criteria described in Case 18 of Volume 3, Test Your Skill In Distinguishing Obstruction From Ileus, the following should be evaluated:
1. Gas distribution: There is a generalized paucity of bowel gas and it is not distributed well.
2. Bowel dilation: This is difficult to comment on since there is not much bowel gas visible.
3. Air-fluid levels: There are several air fluid levels in the left upper quadrant.
4. Orderliness: The supine view does not show a "bag of popcorn" type gas pattern. Nor does it show a "bag of sausages" pattern since there is not much gas here at all.
The paucity of gas is quite remarkable and associated with several air-fluid levels, this is highly suspicious of a bowel obstruction. Additionally, as noted in Case 18 of Volume 3, such a "gasless" (or at least a paucity of gas) bowel obstruction in a young child, is highly suggestive of intussusception.
The right upper quadrant shows a hint of a mass or a "target sign". As described in Case 2 of Volume 1 (The Stomach Flu? - The Target, Crescent, and Absent Liver Edge Signs), this sign is a faint subtle target-like (doughnut shaped) finding in the right upper quadrant. The presence of this sign is highly indicative of intussusception.
This infant actually developed an intussusception during a hospitalization for child abuse. Note that on her admission skeletal survey, her abdominal radiograph shows a normal bowel gas pattern. In retrospect, her clinical presentation of vomiting and lethargy is highly suggestive of intussusception, yet because she was hospitalized for head trauma and child abuse, the diagnosis of intussusception may not be considered as a likely possibility. It's as if hospitalization for an unrelated problem somehow renders inpatients an "immunity" against other medical conditions. True, it is less likely to have two diagnoses to explain a patient's clinical findings, however, no rule in medicine guarantees a single etiology for all clinical findings. Avoid this pitfall by keeping an open mind when evaluating new findings in hospitalized patients.
A barium enema confirmed the intussusception. It could not be reduced. She underwent a surgical reduction of the intussusception. There were no surgical findings to suggest that the intussusception was related to child abuse in any way. She recovered well and was discharged to foster care.