Weill Cornell Neurological Surgery

Head Injury and Trauma

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A head injury is a broad term that describes a vast array of injuries that occur to the scalp, skull, brain, and underlying tissue and blood vessels in the child's head. Head injuries are one of the most common causes of disability and mortality in children. The injury can be mild (bump, bruise, or cut on the head), or moderate to severe in nature due to a concussion, deep cut or open wound, fractured skull bone(s), or internal bleeding and damage to the brain. More severe head injuries are referred to as brain injury, or traumatic brain injury (TBI), depending on the extent of the trauma.

A direct blow to the head, shaking of the child (as in child abuse), or a whiplash injury (from a car accident) may result in bruising of the brain and damage to the internal tissue and blood vessels. As the brain jolts backwards, it can hit the skull on the opposite side and also cause a bruise. The jarring of the brain against the sides of the skull can cause tearing of the internal lining, tissues, and blood vessels that may cause internal bleeding, bruising, or swelling of the brain.

Types of Injuries

Injuries may be concussions, contusions, or skull fractures.

A concussion is an injury to the head area that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event. A contusion is a bruise to the brain. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck.

A skull fracture is a break in the skull bone. There are four types:

Linear skull fractures account for almost 70 percent of skull fractures. In a linear fracture, there is a break in the bone, but it does not move the bone. Children with these fractures are usually observed in the hospital for a brief amount of time, and can usually resume normal activities in a few days. Typically, no interventions are necessary.
Depressed skull fractures may be seen with or without a cut in the scalp. Part of the skull is actually sunken in from the trauma. Usually this type of skull fracture requires surgical intervention to help correct the deformity.
Diastatic skull fractures occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse with the growth of the child. The normal suture lines are widened in this fracture, which is more often seen in newborns and older infants.
Basilar skull fractures are the most serious type of fracture, and involve a break in the bone at the base of the skull. Children with this type of fracture frequently have bruises around their eyes and a bruise behind the ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These children require close observation in the hospital.

Causes

There are many causes of head injury in children. The more common injuries are falls, motor vehicle accidents, or a result of child abuse. The risk of head injury is high in the adolescent population and twice as frequent in males than in females. Studies show that head injuries are more common in the spring and summer months when children are usually active in outdoor activities. The most common time associated with head injuries is late in the afternoon to early evening hours, and on weekends.

Symptoms

Each child may experience symptoms differently, with varying degrees of symptoms associated with the severity of the head injury.

Mild head injury:

Raised, swollen area from a bump or a bruise
Small, superficial (shallow) cut in the scalp
Headache

Moderate to severe head injury (that requires immediate medical attention):

Confusion
Loss of consciousness
Blurred vision
Severe headache
Vomiting
Loss of short term memory, such as difficulty remembering the events that led up to and through the traumatic event
Slurred speech
Difficulty walking
Dizziness
Weakness in one side or area of the body
Sweating
Pale color
Seizures
Behavior changes including irritability
Blood or clear fluid draining from the ears or nose
One eye pupil looks larger than the other
Deep cut or laceration in the scalp
Open wound in the head
Foreign object penetrating the head

Symptoms of a head injury may resemble other medical conditions. For this reason, it is critical to consult the child's physician for diagnosis.

Diagnosis

The full extent of the problem may not be completely understood immediately after the injury, but revealed with a comprehensive medical evaluation/physical examination and diagnostic testing. During the examination, the physician obtains a complete medical history of the child and family and asks how the injury occurred. Trauma to the head can cause neurological problems and may require further medical follow-up.

Diagnostic tests may include:

Blood tests
X-ray - use of invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
Magnetic resonance imaging (MRI) - an imaging procedure using a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body.
Computed tomography (CT) scan - an imaging procedure using a combination of x-rays and computer technology to produce cross-sectional horizontal and vertical images (slices) of the body. A CT scan shows detailed images of any part of the body, including bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
Electroencephalogram (EEG) - a procedure that records the brain's continuous, electrical activity using electrodes attached to the scalp.

Treatment

Specific treatment of a head injury is determined by the physician based on:

Child's age, overall health, and medical history
Extent of the head injury
Type of head injury
Child's tolerance for specific medications, procedures, or therapies
Expectations for the course of the head injury
Parents' opinion or preference

Depending on the severity of the injury, treatment may include:

Ice
Rest
Topical antibiotic ointment and adhesive bandage
Observation
Immediate medical attention
Stitches
Hospitalization for observation
Diagnostic tests
Surgery

Treatment is individualized depending on the extent of the condition and the presence of other injuries. If the child has a head injury, he/she may require monitoring for increased intracranial pressure (pressure inside the skull). Head injury may cause the brain to swell. Since the brain is covered by the skull, there is only a small amount of room for swelling. This causes pressure inside the skull to increase, which can lead to brain damage.

Monitoring Intracranial Pressure (ICP)

ICP is measured in two ways. One method is placing a small hollow tube into the fluid-filled space in the brain. The other method involves a small hollow device (bolt) being placed into the space between the skull and the brain. Both devices are inserted by the physician and attached to a monitor for constant reading of the ICP. If the pressure increases, it can be treated right away. While the ICP device is in place the child will be given medicine to stay comfortable. When the swelling has decreased and little chance of more swelling, the device is removed.

Safety Issues and Long-term Considerations A key issue is promoting a safe playing environment for children and preventing head injuries from occurring. The use of seat belts when riding in the car and properly worn helmets for bicycle riding, in-line skating, and skateboarding may protect the head from sustaining severe injury.

Children who suffer a severe brain injury may lose part(s) of muscle, speech, vision, hearing, or taste function depending on the area of brain damage. Long- or short-term changes in behavior may also occur. These children require life-long medical and physical, occupational, or speech therapy management.

The extent of the child's recovery depends on the type of brain injury and other medical problems that may be present. It is important to focus on maximizing the child's capabilities at home and in the community. Positive reinforcement will encourage the child to strengthen his/her self-esteem and promote independence.

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