When Its Just a Bump on the Head: Interpreting Skull Fractures in the Context of Child Maltreatment

Extra-Axial Blood & Fractures 
from Accidents

CHAMP Education for Child Abuse Medical Providers

Description Below
Description Below

Small extra-axial hemorrhage underlying fracture with overlying soft tissue swelling

Diffuse extra-axial hemorrhage

Extra-axial blood is usually small and underlie or are adjacent to the fracture, NOT diffuse. 

Accessible Version

Similarly, as we are detecting more small bleeds in children, we are noticing that many of the fractures that we see have associated, underlying intracranial bleeds. Most often, these bleeds are small and underlie or are adjacent to the fracture, but NOT diffuse. Many of these small bleeds do not necessarily take on a specific shape, to be able to distinguish epidural vs subdural on CT alone. Therefore, the are often labeled extra-axial hemorrhage. So when I see a skull fracture pattern with overlying soft tissue swelling with a small underlying extra-axial bleed, and the story is of a witnessed fall in an ambulating child, these often do not require further workup.