Penetrating head injury in a child

Tanweer Karim and Margaret Topno

Case Report

A case of a 4 year old male child who presented in the casualty with the history of a fall into a gutter while walking on the road; when he fell, an iron rod penetrated into his head [Figure 1]. There was no history of loss of consciousness or convulsions. At the hospital, the patient was conscious and oriented and responding to verbal commands. His vitals were stable (pulse rate: 100/min, blood pressure: 100/60 mm Hg, and respiratory rate: 18–20/min). The pupils were equal in size and reacting normally to light. The Glasgow coma score (GCS) was 15/15. There was no motor or sensory deficit. Brainstem reflexes were normal. No associated systemic injuries were found.

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Figure 1
Patient on examination table at the time of initial presentation

After primary and secondary evaluation, basic blood investigations and X-ray studies were done of the skull [Figure 2], cervical spine, and chest. Imaging showed that the iron rod (12 mm in diameter) had penetrated approximately 3.5 cm into the brain parenchyma of the right frontoparietal region. A CT scan of the head was not possible immediately because the scanner was out of order. To avoid any delay and aggravation of the injury, the patient was shifted to the operation theater after obtaining written consent [Figure 3]. Circumferential craniectomy was performed and the iron rod was removed along with a bone flap. The tip of the rod was seen to be 3.5 cm inside the brain parenchyma of the right cerebral hemisphere in the region of the precentral gyrus. There was no vascular injury. Necrotic brain tissue, the hematoma, and bone fragments were removed. The wound was closed after debridement of the track. The patient had an uneventful recovery and was able to walk about on day 4. There was no motor or sensory loss and he was able to communicate verbally in a coherent manner.

Figure 2
X-ray skull showing iron rod penetrating inside

The absence of major neurological deficits was possible because the patient was right-handed, with left cerebral dominance. CT scan of the head was done on the 6th day to look for intracranial hematoma or abscess formation. The patient had an uneventful recovery and was discharged on the 10th postoperative day with advice to take syp. Gardenal (phenobarbitone), 30 mg at bedtime for 6 months. At the time of discharge his neurological examination was normal. He was advised to come for follow-up monthly and to report immediately if there were any abnormal movements of the body parts or high-grade fever with vomiting and drowsiness. There has been no report of seizure till date. At present he is not receiving any treatment. His growth and development is normal for his age. Police investigation ruled out the possibility of child abuse.

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Figure 3
Patient in operation theatre