This is a 7 month old female who presents to the 
emergency department with a chief complaint of a 
growing lump on the side of her head.  A cousin who 
was baby sitting the infant six days ago had  placed her 
on a couch.  The infant fell off the couch.  The infant's 
grandmother was in the home at the time.  The infant 
cried right away.  There was no loss of consciousness 
or drowsiness noted.  Two days later (four days ago), 
mother noted a lump developing on the right side of the 
infant's head.  Since then, mother has noted that the 
lump has become larger and the lump feels like a large 
soft spot in her head.  There is no history of vomiting or 
other trauma.
     Exam:  VS T37.5 (rectal), P140, R36, BP 75/40, 
weight 5th percentile for age, height 25th percentile for 
age.  She is alert and active in no distress.  Anterior 
fontanelle flat.  A 10 cm region of swelling is noted over 
the right parietal region raised about 2 to 3 cm.  The 
swelling is soft.  PERRL, red reflex present bilaterally.  
Fundi difficult to view.  TM's no blood.  Nose clear.  Oral 
clear, moist.  Neck non-tender, supple.  Heart regular 
without murmurs.  Lungs clear.  Trunk without bruising.  
Abdomen soft, flat, bowel sounds active.  No abdominal 
tenderness or masses.  No hernias.  Normal genitalia.  
Extremities without swelling, deformity, or bruising.  
Tone good.  Uses all extremities well.
     A skull series is obtained.

View skull series. 

     Clinically, this infant appears to have a subgaleal 
hematoma.  These usually are brought to medical 
attention several days after sustaining an underlying 
skull fracture.  The presentation is often not immediate 
since the hemorrhage from the fracture forms a tight 
and palpably rigid swelling under the aponeurosis of 
Galen.  As blood from the hematoma is resorbed, the 
swelling softens.  This "soft spot" on the infant's head is 
then noted by parents, often prompting a visit to a 
physician.  In most instances, there are no 
complications, since several days have elapsed since 
the head trauma without the infant exhibiting any signs 
or symptoms of brain injury.  Radiographs of the skull 
would most often not alter one's clinical approach 
except in a case such as this.
     This skull series shows extensive fractures of the 
right parietal skull.  One would expect to see a simple 
linear fracture in this region if the trauma were 
accidental.  Additionally, there are extensive fractures 
over the occipital skull and the contralateral parietal 
skull as well.  A simple fall off a couch could not 
possibly account for all these fractures.  Child abuse is 
likely.  A CT scan of the brain is performed.

View CT scan.

     This high CT scan cut shows a bone window on the 
left and a brain window on the right.  The open anterior 
fontanelle is noted at the top of the both images.  The 
large right parietal scalp swelling (subgaleal hematoma) 
is noted.  The bone window on the left shows a large 
right parietal fracture.  A smaller left parietal fracture is 
also evident.  The coronal sutures are visible.  There 
are several lucencies in the occiput.  Two of these are 
the lambdoidal sutures while the others are occipital 
fractures.  The brain is normal.  Lower cuts do not 
demonstrate cerebral hemorrhages or edema.  The 
posterior interhemispheric subdural hematoma is not 
evident on the lower cuts.  This finding would be 
indicative of shaken infant syndrome as noted on Case 
1 of Volume 1.
     A skeletal survey is obtained.

View skeletal survey.

     No other fractures are identified on this skeletal 
survey.  The upper extremities are not shown here.  
They are negative for fractures as well.

     Because of the likelihood of child abuse and the 
potential for repeated inflicted head trauma, the infant 
is hospitalized and the child protective service is 
notified.  During hospitalization, this infant does well.  
There is good weight gain and her neurological function 
and developmental evaluation are normal.  A retina 
exam performed by an ophthalmologist is negative for 
hemorrhages.

     On hospital day three, she is noted to be less active 
than she has been and she vomits three times.  
Abdominal examination is negative.  She vomits again 
and is noted to be lethargic.  A nasogastric tube is 
placed.  A repeat CT scan is obtained to rule out a 
hemorrhage.  The repeat CT scan fails to find any brain 
abnormalities.  The skull fractures and scalp swelling 
are unchanged.  

     Develop a differential diagnosis at this point and a 
diagnostic plan.  An IV is started.  Laboratory studies 
are drawn and she is started on IV fluids at a moderate 
rate.


     An abdominal series is ordered as part of her 
evaluation.

View abdominal series.

     The supine view is on the left and the upright view is 
on the right.  Is this abdominal series helpful?  How 
does it affect the differential diagnosis?  What should 
be done at this point?



     This abdominal series shows a paucity of bowel gas.  
An NG tube is in the stomach.  Is this pattern consistent 
with an ileus or a bowel obstruction?  Using the criteria 
described in Case 18 of Volume 3, Test Your Skill In 
Distinguishing Obstruction From Ileus, the following 
should be evaluated:
     1.  Gas distribution:  There is a generalized paucity 
of bowel gas and it is not distributed well.
     2.  Bowel dilation:  This is difficult to comment on 
since there is not much bowel gas visible.
     3.  Air-fluid levels:  There are several air fluid levels 
in the left upper quadrant.
     4.  Orderliness:  The supine view does not show a 
"bag of popcorn" type gas pattern.  Nor does it show a 
"bag of sausages" pattern since there is not much gas 
here at all.

     The paucity of gas is quite remarkable and 
associated with several air-fluid levels, this is highly 
suspicious of a bowel obstruction.  Additionally, as 
noted in Case 18 of Volume 3, such a "gasless" (or at 
least a paucity of gas) bowel obstruction in a young 
child, is highly suggestive of intussusception.
     The right upper quadrant shows a hint of a mass or 
a "target sign".  As described in Case 2 of Volume 1 
(The Stomach Flu? - The Target, Crescent, and Absent 
Liver Edge Signs), this sign is a faint subtle target-like 
(doughnut shaped) finding in the right upper quadrant.  
The presence of this sign is highly indicative of 
intussusception.
     This infant actually developed an intussusception 
during a hospitalization for child abuse.  Note that on 
her admission skeletal survey, her abdominal 
radiograph shows a normal bowel gas pattern.  In 
retrospect, her clinical presentation of vomiting and 
lethargy is highly suggestive of intussusception, yet 
because she was hospitalized for head trauma and 
child abuse, the diagnosis of intussusception may not 
be considered as a likely possibility.  It's as if 
hospitalization for an unrelated problem somehow 
renders inpatients an "immunity" against other medical 
conditions.  True, it is less likely to have two diagnoses 
to explain a patient's clinical findings, however, no rule 
in medicine guarantees a single etiology for all clinical 
findings.  Avoid this pitfall by keeping an open mind 
when evaluating new findings in hospitalized patients.
     A barium enema confirmed the intussusception.  It 
could not be reduced.  She underwent a surgical 
reduction of the intussusception.  There were no 
surgical findings to suggest that the intussusception 
was related to child abuse in any way.  She recovered 
well and was discharged to foster care.