• N Z Melhem and E L Abrahamson.
• Paediatric A&E, Chelsea and Westminster Hospital, London, United Kingdom.
• Emerg Med J. 2013 Oct 1;30(10):877.

Objectives & BackgroundSubgaleal haematoma is associated with skull fracture in infants and young children. If the onset is reported to have appeared some time after the suggested mechanism, history may be placed in doubt raising safeguarding concerns. This can lead to social care intervention driven by medical opinion. We performed this study to evaluate our hypothesis that delay in haematoma is common in simple accidental head trauma.MethodsWe performed a 10 year retrospective review (2003-13) of all cases of skull fracture under 2 years of age presenting to our paediatric emergency department. We analysed the case records of those who had a delayed presentation with subgaleal haematoma, as defined as more than 24 hours after the injury, or where no injury was recalled.ResultsA total of 47 eligible patients were included. 12 (26%) presented more than 24 hours after reported injury (24 to 504 hours, mean 137) and a further 3 (6%) had no reported accident to explain a fracture. All of these cases presented with isolated subgaleal haematomas and no other clinical symptoms or signs. One case had intracranial abnormalities on CT scan whilst the remainder had simple linear skull fractures. In 8 of the 12 cases with a history of injury (67%), safeguarding concerns were carefully considered and excluded. No safeguarding considerations were documented in the 4 other cases. In the 3 cases with no history of injury, full child protection assessments occurred.ConclusionWhilst every case of skull fracture in infants and young children must be thoroughly assessed for safeguarding concerns, our findings suggest that delayed onset of a subgaleal haematoma can be consistent with accidental injury. It is important to take this into account when offering medical opinion on such cases, to avoid unnecessary social care and legal intervention.

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