Injury/Trauma to the Central and Peripheral Nervous Systems

Question 1

What is the leading cause of overall pediatric mortality?

Answer 1

Accidents account for 40% of all pediatric deaths, making them the leading cause of pediatric mortality overall.

Question 2

List the most common side effect of scalp laceration.

Answer 2

Scalp lacerations lead to marked and alarming bleeding because of the rich anastamotic blood supply and the limited ability of the blood vessels to constrict in the dense connective tissue layer.

Question 3

What is the recommended treatment for scalp lacerations?

Answer 3

Primary closure is best, and lacerations tend to heal well without infection.

Question 4

In what area of the skull does a fracture most commonly occur in children?

Answer 4

> 80% of skull fractures are simple linear or diastatic fractures; the parietal area is the most common location.

Question 5

What type of fracture is indicated by bilateral raccoon eyes?

Answer 5

Basilar skull fracture

Question 6

What type of fracture is indicated by the presence of otorrhea and rhinorrhea?

Answer 6

Basilar skull fracture

Question 7

When would you do a CT scan with bone windows instead of plain skull x-rays in a child < 3 years of age with suspected skull fracture? (7)

Answer 7

If you suspect an underlying intracranial lesion, which should be suspected in the following scenarios: depressed or comminuted skull fracture, LOC lasting ≥ 5 minutes, altered mental status or irritability, bulging fontanelle, focal neurologic signs or deteriorating neurologic condition, vomiting at least 5 times or for > 6 hours, and nonimpact seizures in children < 6 months of age.

Question 8

Following injury, how long does it usually take for acute intracranial bleeds to develop?

Answer 8

Most acute intracranial bleeds develop within 6-8 hours of injury.

Question 9

How are most uncomplicated linear skull fractures managed?

Answer 9

Simple linear fractures do not require specific therapy; advise parents not to restrict the child’s normal activity and repeat skull x-ray in 3 months to show union.

Question 10

When do pond fractures of the skull require surgical elevation?

Answer 10

These fractures typically do not require surgical elevation unless they are depressed > 0.5 cm.

Question 11

Which type of basilar skull fracture requires observation in the hospital?

Answer 11

Basilar skull fractures that result in otorrhea or rhinorrhea require hospital observation.

Question 12

Under what conditions are you most likely to see diffuse axonal injury?

Answer 12

Diffuse axonal injury is seen most commonly with acceleration-deceleration injuries from motor vehicle accidents.

Question 13

Describe an epidural hematoma.

Answer 13

This is bleeding that occurs between the skull and the dura. On CT scan the hematoma is biconvex/lentiform. *** Include image 12-8

Question 14

What is the classic presentation of a child with epidural hematoma?

Answer 14

A child undergoes head trauma, loses consciousness, and then regains consciousness for several hours before neurologic status starts to worsen.

Question 15

What two clinical scenarios most commonly lead to the development of epidural hematoma?

Answer 15

Temporal bone fracture with resulting tear of the middle meningial artery or a tear in the bridging veins or dural sinuses.

Question 16

How does early herniation present in a child with epidural hematoma?

Answer 16

Early herniation is characterized by a dilated pupil ipsilateral to the hematoma, progressing to a complete CN 3 palsy and a contralateral hemiplegia.

Question 17

What are the (3) most common causes of spinal injury in children?

Answer 17

Motor vehicle crashes, falls, and diving injuries.

Question 18

What is the most common cause of peripheral nerve injury in an infant?

Answer 18

Birth trauma

Question 19

List four risk factors for the development of peripheral nerve injury as part of the birthing process.

Answer 19

Macrosomia, use of forceps, shoulder dystocia, and gestational diabetes. 50% are due to shoulder dystocia.

Question 20

What is the typical management and prognosis of brachial plexus injury sustained during the birthing process?

Answer 20

Most patients make a full recovery. Initial treatment consists of observation and appropriate positioning. PT is sometimes used. After 3 months if there is no improvement, surgery would be indicated.

Question 21

Which nerve roots are affected in Erb palsy (Erb-Duchenne palsy)?

Answer 21

C5, C6, and occasionally C7.

Question 22

How does Erb-Duchenne-type injury present?

Answer 22

The infant presents with a sagging shoulder, an arm that hangs limp in internal rotation, and a pronated wrist (“waiter’s tip position”). ***Include Figure 12-5

Question 23

What is the treatment and prognosis for infants with Erb palsy?

Answer 23

Treatment involves placing the arm in abduction and external rotation. > 90% of infants have full recovery within 3 months. Those who do not improve with conservative management need evaluation for possible surgical repair.

Question 24

What nerve roots are involved in Klumpke palsy (Dejerine-Klumpke-type injury)?

Answer 24

C8-T1

Question 25

How does Dejerine-Klumpke-type injury present?

Answer 25

Lower plexus root injuries show more sensory and vasomotor involvement, with paralysis of the extensors of the forearm, flexors of the wrist, and intrinsic muscles of the hand. If T1 is involved, Horner syndrome and cervical sympathetic damage are likely.

Question 26

What is the recommended treatment and prognosis for Klumpke palsy?

Answer 26

Treat by splinting the forearm and wrist in a neutral position. Most recover in 3-6 months but do not improve as much as those with Erb palsy. Surgery with microvascular techniques is often beneficial in cases that are severe or do not resolve.

Question 27

What is serratus anterior palsy?

Answer 27

It occurs due to involvement of the long thoracic nerve leading to paralysis of the serratus anterior muscle and presents as winging of the scapula.

Question 28

In which patients is serratus anterior palsy most likely to occur?

Answer 28

It is most common in boys who pitch baseballs, lift weights, or carry heavy loads.

Question 29

What is the recommended treatment for serratus anterior palsy?

Answer 29

Use of an arm sling during the 1st week alleviates discomfort. Treat with ROM exercises, followed by active shoulder-strengthening exercises.

Question 30

In what location are IM injections contraindicated during infancy?

Answer 30

IM injections during infancy are contraindicated in the intragluteal area due to the association with iatrogenic sciatic nerve injury.