Neurological health risk in children with blunt head injuries: fashion hair beads

An intriguing article published in the December 2008 online issue of Journal of Neurosurgery: Pediatrics may come as quite a surprise to parents, especially those with little girls.

The article, "Radiolucent hair accessories causing depressed skull fracture following blunt cranial trauma" discusses the cases of a 4-year-old and 2 ½-year-old treated for blunt head trauma. The article is posted online at: http://thejns.org/doi/full/10.3171/PED.2008.2.12.424.

Authors are Omar N. Syed, MD, Richard C. E. Anderson, MD, Neil A. Feldstein, MD, Todd C. Hankinson, MD, and William J. Mack, MD, physicians in the Department of Neurological Surgery, Columbia University Medical Center.

Blunt head trauma is commonly encountered by pediatric neurosurgeons and emergency physicians. Every year, the U.S. Consumer Product Safety Commission provides head injury statistics for patients treated at U.S. hospital emergency rooms. More than 550 product codes were included in the 2007 Product Summary Report. In 2007, an estimated 1.1 million people were treated for head injuries related to common products found inside the home. Beds are among the top five products that contribute to head injuries, with an estimated 106,513 injuries in 2007, 63,269 of which were in children age 14 and younger. Common household products that can actually penetrate the head include wires, plugs, nails, kitchen utensils, writing instruments, hair accessories, scissors, and toys, among others.

"Children younger than age 2 are at particularly high risk for neurological injury because the skull is not fully ossified and small forces may lead to penetration of the skull and dura," stated Dr. Anderson. The complications of these injuries can be severe, including skull fracture, subdural and epidural hematoma, pneumocephalus, cerebral hemorrhage, infection, seizure, focal neurological deficits, and vascular complications.

"Hair beads are radiolucent and thus are difficult to differentiate on radiologic scans from the adjacent soft tissue - the air-filled hollow core may be mistaken for benign air that became entrapped at the time of injury. Fashion hair accessories present a hidden and often overlooked health risk in children who have suffered blunt head trauma, significant enough to cause skull fractures and complicate diagnosis and treatment," remarked Dr. Anderson.

Injury from blunt trauma by common household objects carries the potential for significant morbidity and mortality. "The absence of an obvious foreign body on physical examination in one of these two cases, demonstrates the importance of considering fashion hair accessories in the differential diagnosis when children present with head injury following blunt trauma," concluded Dr. Anderson.

Case 1

A 4-year-old girl fell to the floor from a height of about 4 feet. She struck her head on the wooden leg of a bunk bed and then onto the carpeted floor. There was no loss of consciousness, vomiting, or seizure activity. On examination, the patient was neurologically intact. A 2.5-cm right parietal scalp laceration, moderate bleeding, and an underlying hematoma were observed. A defect in the skull could be palpated, but no foreign object was identified. Emergency room physicians closed the wound with staples. Skull radiography showed a 2-cm deformity in the right parietal bone. The CT scan revealed a right parietal skull fracture with depressed fragments. At the fracture site, a spherical radiolucency was noted. In the operating room, neurosurgeons found a 1.2-cm plastic hair bead embedded in her skull. This was easily removed, and the skull fracture was elevated. The patient tolerated the procedure and there were no complications.

Case 2

A 2 ½-year-old girl fell from a bunk bed. There was no loss of consciousness, nausea, vomiting, or seizure activity. Initial examination at another hospital revealed a 1.5-cm plastic hair bead protruding from the scalp laceration in the frontal midline. The girl was transferred to Columbia University Medical Center, where the CT scan revealed a comminuted, depressed fracture of the anterior paramedian frontal bone, a small epidural hematoma, and two small foci of air, causing swelling in the soft tissue of the frontal lobes. A CT angiogram showed posterior displacement of the superior sagittal sinus but no evidence of thrombosis. The patient was brought immediately to the operating room. After the scalp was opened, the foreign body embedded in the bone was identified and easily removed, exposing the fragments of bone beneath. A small craniectomy within the fractured bone allowed identification of the dura mater, and the bone fragments were carefully dissected from the dura. The dura was found to have a split-thickness tear, but there was no evidence of bleeding or cerebrospinal fluid leak. The patient tolerated the procedure and there were no complications.

The authors report no conflict of interest.

Founded in 1944, the Journal of Neurosurgery , the official scientific journal of the AANS, has been recognized by neurosurgeons and related medical specialists worldwide for its authoritative and cutting-edge clinical articles, laboratory research papers, case reports, literature reviews, technical notes, book reviews, and more. Each successive editor-in-chief - from Louise Eisenhardt to the current editor, John A. Jane, Sr. - has played a key role in shaping a publication that stays on the cutting edge of a constantly advancing specialty. Each manuscript is reviewed by at least three editorial board members, in addition to the Editor and occasionally one or more expert reviewers.

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