Presentation
Admitted unresponsive and flat. Intubated in ED. No history of being unwell. Apyrexial. Initial bloods including venous gas normal.
Patient Data
Intubated child with NG tube. ET and NG tubes in appropriate positions.
Lungs are under expanded by grossly clear. No effusion. Normal cardiac size.
Multiple, bilateral rib fractures at the costochondral junction.
Subdural acute hemorrhage (< 2 weeks) predominantly on the left with extension into the interhemispheric fissure and over the tentorium. Midline shift to the right with subfalcine herniation.
Grossly abnormal cerebral parenchyma with loss of grey-white differentiation and features of global cerebral edema with a reduction in ventricular volume and generalized sulcal effacement.
MRI confirms the CT findings.
Left-sided subdural hemorrhage. In addition, there is a posterior fossa left-sided subdural hemorrhage.
The degree of parenchymal injury is revealed with globally abnormal parenchymal signal affecting both white and grey matter.
Left:
5,6,7,8,9 costochondral, with callus (>1 weeks).
Right:
5,6 costochondral, with callus (1 weeks).
9,10 posterior, with callus (1 week).
Confirms the fractures.
Right metaphyseal corner fracture (healed).
Follow up imaging highlights the degree of parenchymal loss from that original injury. Cystic encephalomalacia. Almost no cerebral tissue. Large subdural effusions.
Case Discussion
This case demonstrates the importance of a full and thorough assessment of the chest x-ray of the unwell child. Rib fractures in a young child are always abnormal. They are usually the result of non-accidental inflicted trauma although there are some situations where accidental trauma can result in rib fractures.
The CT confirms the reason for the presentation with profound cerebral injury and additional subdural collections with acute hemorrhage. Dense blood suggests it is less than 2 weeks old. Mixed density subdural collections do not infer bleeding of different ages.
The follow-up imaging demonstrates the profound and extensive sequela of this type of injury.
The case was concluded with the defendant's plea of guilty after changing testimony after describing a shaking episode in the hours prior to admission.
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