Differentials
Intracranial haemorrhage
SIGNS / SYMPTOMS
Typically presents with loss of consciousness or period of decreased alertness, potential seizure activity (or loss of bowel and bladder continence), headache, weakness or sensory changes, or changes in cognition, speech, or vision.
INVESTIGATIONS
Computed tomography (CT) will show subdural/epidural fluid collection.
In subdural haematomas, fluid is usually crescentic in shape and can cross suture lines; a midline shift may be noted.
In epidural haematomas, fluid collection shows lenticular shape that does not cross suture lines.
Cerebral swelling may manifest as the loss of grey-white matter distinction. Subdural haematomas that have a hypodense "swirl" inside them signify potential hyperacute haematoma with active bleeding. Diffusely hypodense and isodense subdural haematomas indicate chronicity.
Suture lines in children
SIGNS / SYMPTOMS
No clinical evidence of injury, no history of head trauma.
INVESTIGATIONS
CT scan allows differentiation between fractures and sutures based on location and anatomy.
Cephalhaematoma
Child abuse
SIGNS / SYMPTOMS
History of previous hospital attendance for non-accidental injury.
Signs and symptoms inconsistent with history; unexplained bruising; faltering growth for age. Other signs of abuse that may be present include retinal haemorrhages, coexisting apnoea or some other form of acute respiratory compromise, coexisting bruising to the head, neck or torso, or rib or long-bone fractures.[12][13][14]
Unexplained dental injury and/or the presence of torn lingual or labial frenulum.[32]
INVESTIGATIONS
Ophthalmoscopy may show retinal haemorrhage.
Skeletal survey may identify occult fractures.
Osteogenesis imperfecta (OI) and other bone fragility disorders
SIGNS / SYMPTOMS
Positive family history (autosomal dominant), history of fractures after minor trauma or deafness, discoloration of the sclera to a blue-grey colour (osteogenesis imperfecta [OI] types 1 and 3), dental discoloration, poor muscle tone.
INVESTIGATIONS
X-ray reveals wormian (intrasutural) bones, reduced bone density, and evidence of multiple fractures.
Mutation analysis of COL1A1 and COL1A2 genes from fibroblast RNA may also be performed. Genetic testing is possible in a few centres, but is expensive. Genetic testing is only recommended in OI types 2 and 4; other types are diagnosed clinically and radiologically.
Skin biopsy and culture of fibroblasts may be performed, enabling a collagen synthesis assay that may show quantitative or qualitative differences in collagen in patients with OI.
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