Head injury
Key points
Monro-Kellie Doctrine
Brain 80% tissue, 10% blood, 10% CSF
Axonal shear leads to diffuse axonal injury
A. Extracranial Injuries
SCALP Layers & Clinical Relevance
Skin: Rich in hair follicles (folliculitis risk) and sebaceous glands (risk of cysts).
Connective Tissue: Dense; limits vessel retraction → profuse bleeding
Aponeurosis: Galea aponeurotica links frontalis and occipitalis; injury causes gaping wounds.
Loose Areolar Tissue: Infection and blood spread easily → potential intracranial spread via emissary veins.
Pericranium: Adheres to sutures; haematomas confined to specific bones
Emissary veins are valveless connections between intra- and extracranial systems → risk of infection spread and air embolism, especially with skull base fractures
Birth Injuries to the Scalp
Risk Factors: Macrosomia, Instrumental delivery (forceps, vacuum), Prolonged or rapid labour, Abnormal presentations (e.g. breech)
Types of Injury:
Caput Succedaneum: Oedema crossing sutures; present at birth; resolves spontaneously.
Cephalohaematoma: Subperiosteal bleeding, confined to one bone; appears hours after birth; possible complications: jaundice, anaemia, calcification -
Bleeding elevates periosteum, limited by sutures
Conservative management - 80% resorb in 2 weeks, may calcify
If infected - perform needle aspiration for culture
Subgaleal Haemorrhage:
Rare but can be a life-threatening emergency
Caused by rupture of emissary veins, which drain the scalp veins into the dural sinuses
Most commonly associated with vacuum-assisted and forceps delivery
Can also occur after head trauma or spontaneously
Located superficially to the periosteum, allowing subgaleal haematomas to cross suture lines and surround the entire skull
The haematoma may extend into the neck, unlike a cephalohaematoma, which remains confined to the skull and does not cross suture lines
Management: Observation for caput; imaging and monitoring for cephalohaematoma; urgent stabilisation and NICU care for subgaleal haemorrhage
B. Cranial Injuries
Depressed Skull Fractures
Simple: No breach of skin/dura
Compound: Open fracture → infection risk.
Ping Pong Fractures: Seen in neonates; skull indents without break
Clinical signs: Visible depression, swelling, seizures, CSF leak
Management: Observation if uncomplicated. Surgery if >5 mm depression, cosmetic concern, neurological signs, CSF leak
Basal Skull Fractures
Signs: Battle’s sign, raccoon eyes, haemotympanum, CSF leak, cranial nerve deficits.
Diagnosis: CT, MRI, beta-2 transferrin for CSF confirmation.
Management: Observation, neurosurgery for complications
Vaccinate against strep pneumoniae
No evidence for prophylactic antibiotics - do not prevent meningitis and select out resistant organisms
C. Intracranial Injuries
Primary Injuries: Concussion, contusion, laceration; extradural, subdural, subarachnoid, intracerebral bleeding.
Secondary Injuries: Ischaemia, hypoxia, oedema, raised ICP, metabolic disturbances, seizures, infections.
Extradural Haematoma: Arterial bleed; CT shows biconvex hyperdense lesion; requires emergency surgery.
Subdural Haemorrhage: Bridging vein rupture; associated with trauma and NAI; managed with stabilisation, ICP control.
Subdural Haemorrhage in NAI: Triad of subdural bleed, retinal haemorrhage, encephalopathy.
Subarachnoid Haemorrhage: Causes include AVMs, trauma, coagulopathy; managed with nimodipine, seizure control, neurosurgery.
Traumatic Brain Injury: 5 Key Principles
1. Resuscitation: CCABCDEFGH protocol
2. Neurological Assessment: AVPU, GCS, pupils, limbs, fundoscopy
3. Prevent Secondary Injury: Maintain normoglycaemia, normotension, normothermia; optimise oxygen and CO₂; treat seizures, pain, anxiety
4. Medical Therapy: Mannitol, hypertonic saline
5. Referral: To neurosurgical/specialist centre
Elevate head of bed to 15-30 degrees
Neurosurgical intervention if necessary
Example management ladder:
ICP bolt > paralyse > drain CSF > mannitol or hypertonic saline > hyperventilate > hypothermia > craniectomy > barbiturates
Hyperventilation and fluid restriction no longer routinely used
General aim to keep ICP <40mmHg
Post traumatic hydrocephalus can present as late as 2-3 years after injury
Sub-dural bleeds
Acute <3d, sub acute 3-10d, chronic >10d
In infants common cause is fall back from sitting
Lacerated bridging veins
Can present with raised ICP - usually seizure in infants
Signs of raised ICP:
Neurologic signs
Frontal bossing
Setting sun eyes
Dilated scalp veins
Enlarged head
Bulging fontanelles
Papilloedema
Atlanto-axial subluxation
Spontaneous - Rheumatoid arthitis, URTI (Grisel syndrome)
Trauma
'Cock robin' head position with torticollis
In general spinal injuries should be treated non-operatively in children where possible
C-spine injury is rare in children - 1.5% of all major trauma - SCIWORA is 20% of these
Pseudosubluxation is common in <7y - anterior displacement of C2 on C3 or C3 on C4
Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. June 2025
Page edited by Mrs Charnjit Seehra BSc. June 2025
References
Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 17 Traumatic Brain Injury
Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 18 Pediatric Orthopedic Trauma
Petty, John, et al. "Blunt Cerebrovascular Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2020. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829577/all/Blunt_Cerebrovascular_Trauma.
Keller, Martin S, et al. "Cervical Spine Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829476/all/Cervical_Spine_Trauma.
Raines DA, Krawiec C, Weisbrod LJ, et al. Cephalohematoma. [Updated 2024 Jun 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470192/
Jones J, English K, Ranchod A, et al. Subgaleal hematoma. Reference article, Radiopaedia.org (Accessed on 26 Aug 2024) https://doi.org/10.53347/rID-13458