Skull Depression In A 9-Month-Old Girl

Alvaro Galvis, MD, PhD*2. Anthony Shoo, MD*3. Aaron R. Shedlock, MD* 1. *Department of Pediatrics, University of Nevada Las Vegas School of Medicine, Las Vegas, NVA 9-month-old unvaccinated African American girl presents to the emergency department for the evaluation of an abnormal head “bump.” The mother reports that 5 days before presentation the patient rolled over off a bed and fell 3 feet to the ground. After the fall the girl exhibited no behavioral changes, apparent pain, or emesis. Since the incident, the mother reports that the patient has been doing well, although she became concerned 2 days ago when she noticed a depression on her daughter’s head while bathing her.The infant was born full term but small for gestational age. The mother reports no complications with the birth but that a radiograph was obtained in the nursery showing bilateral “bowed legs.” However, the patient was lost to follow-up after nursery discharge with no establishment of a primary care physician.On examination in the emergency department, her vital signs are as follows: temperature, 98°F (36.7°C); heart rate, 156 beats/min; respiratory rate, 34 breaths/min; and oxygen saturation, 98% on room air. The patient’s weight and height are both below the third percentile. The patient is interactive and playful. There is a small depression 1.6 in (4 cm) in diameter on the left parietal region of her head, with no crepitus or tenderness to palpation. The remaining physical examination findings are normal except for yellowish translucent teeth.Laboratory studies are obtained and show a complete blood cell count and complete metabolic profile within normal limits. A head computed tomographic scan without contrast illustrates a 13-mm depressed comminuted left parietal skull fracture with possible small underlying subarachnoid hemorrhage (Fig 1). Additional imaging and laboratory evaluation lead …