COTW 9/1/22: A 20 day old infant presenting after a headstrike
A 20 day old infant presents after an accidental fall. Patient was being held by his father when his older sibling grabbed onto the father’s arm. The father accidentally dropped the patient and he fell approximately 4 feet and struck his head. The patient had no loss of consciousness, cried immediately after impact, has tolerated PO, and is otherwise at his baseline. On exam, the child appears extremely well and appropriate. There was questionable temporal bogginess, so POCUS was performed.
The bright white line aproximately 0.75 cm in depth is the skull. Above the skull is an anechoic stripe which represents a scalp hematoma.
A step off can be seen when scanning along the skull. There is also a fluid collection deep to the skull, concerning for a traumatic intracranial hemorrhage.
Based on what was seen on POCUS, cross sectional imaging was performed.
Left Temporal epidural hematoma measuring 6 mm
The patient was transferred to a pediatric trauma hospital where he was observed for 2 days and discharged home without any surgical intervention. The child is continuing to do well at 2 week followup :)
How to identify Skull Fractures on Ultrasound
Use a linear transducer and place the probe at the area of tenderness/swelling
Scan across the area in 2 planes to look for step offs on the skull.
Cranial Sutures can be mistaken for fractures in infants. To ensure that you are not mistaking a suture for a fracture, mind the following:
Look at the morphology of the defect: fractures will have jagged edges whereas suture lines will appear smooth
A good practice to ensure that you are not mistaking a fracture for a suture line is to follow the defect to one of the fontanelles. If you see a similar pattern on the contralateral side, you are likely looking at a suture.
Take Home Points
POCUS can be used as an adjunct for your decision making in pediatric head trauma
Be careful not to mistake a suture line for a fracture
Reassuring POCUS findings SHOULD NOT sway you away from obtaining cross sectional imaging. If the story and physical exam are concerning, you should proceed to CT regardless of the POCUS findings.