Subgaleal Hemorrhage Secondary to Child Physical Abuse in a 4-Year-Old Boy

Abstract

Subgaleal hemorrhage is commonly described in the neonatal population but is a rare injury in young children and adolescents. Though infrequently seen, it can follow blunt head trauma or hair pulling. This case report details a 4-year-old African American boy with massive subgaleal hemorrhage and bilateral periorbital swelling and ecchymosis as a result of hair pulling in the setting of child physical abuse. The patient was evaluated in the emergency department for swelling of his scalp several hours after reportedly bumping his head on a chair. He was discharged home after a head computed tomography only confirmed soft tissue hematoma. The following morning, the findings progressed and he returned to the emergency department. He was triaged as a trauma and initially evaluated by the emergency physician, pediatric trauma surgeon, and pediatric neurosurgeon. Head computed tomography scan confirmed diffuse scalp edema without skull fracture or intracranial pathology. The child abuse specialty service was consulted for suspected child physical abuse. Their examination revealed numerous scattered bruises on the trunk and thighs, several of which were patterned. Local police investigation resulted in the patient's grandfather confessing to striking the patient with a belt and picking him up from the ground by his hair, the latter of which is a mechanism consistent with the patient's dramatic scalp and facial findings. The authors encourage consultation by a specialist in child abuse pediatrics for subgaleal hemorrhage and/or raccoon eyes in the presence of minor trauma, as well as thorough head-totoe skin examination for all children presenting with injuries.

Subgaleal hematoma evacuation in a pediatric patient: A case report and review of the literature

“…The mechanism likely involves accumulation of blood in the subgaleal layer, where emissary veins drain superficial scalp veins to the dural sinuses. [ 1 ] The previous reports in the literature have cited spontaneous SGH with workup uncovering blood dyscrasias, including impaired platelet aggregation,[ 14 ] Vitamin K deficiency,[ 30 ] or deficient/nonfunctional coagulation factors. [ 4 , 12 , 29 ] Accordingly, a comprehensive hematological workup should ensue when presented with a pediatric patient with a diagnosis of SGH, especially without compression has also been advocated,[ 3 ] as a prelude to surgical intervention.…”

“…[ 22 , 26 , 38 ] A characteristic clinical finding may present as a patient’s inability to open their eyes. [ 1 ] Worse, if there is leakage of blood beyond subgaleal attachment points associated with the zygomatic arch, airway compromise and skin necrosis may result. [ 21 ] Von Willebrand’s disease, the most common inherited bleeding disorder, has also been discovered in patient’s manifesting with subgaleal hemorrhage following hair braiding.…”

Orofacial manifestations of child maltreatment: A review

“…When this mechanism is suspected, inspect the scalp for evidence of traction alopecia, as these children often have unexplained patches of missing hair (Figure 9). 58 Bruising to the eyelid is more concerning for direct impact to the eye. 13 A hyphema presents as blood in the anterior chamber of the eye between the cornea and pupil and are a result of direct trauma to the eye with an object.…”

“…When this mechanism is suspected, inspect the scalp for evidence of traction alopecia, as these children often have unexplained patches of missing hair (Figure 9). 58 Bruising to the eyelid is more concerning for direct impact to the eye 13 …”

Acute sunburn presents with scalp edema: A case report and literature review

“…Subgaleal hemorrhage is often the result of blunt trauma to the head. 1 Imaging examination of the head, such as CT scan, can confirm the diagnosis.…”