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Head injuries are one of the most common causes of disability and death in children. The injury can be as mild as a bump, bruise (contusion), or cut on the head. Or it can be moderate to severe in nature due to a concussion, deep cut or open wound, fractured skull bone(s), or from internal bleeding and damage to the brain.
A head injury is a broad term that describes a vast array of injuries that occur to the scalp, skull, brain, and underlying tissue and blood vessels in the child's head. Head injuries are also commonly referred to as brain injury, or traumatic brain injury (TBI), depending on the extent of the head trauma.
A concussion is an injury to the head area that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event.
A contusion is a bruise to the brain. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck.
A skull fracture is a break in the skull bone. There are four major types of skull fractures, including the following: Linear skull fractures - This type accounts for almost 70 percent of skull fractures. In a linear fracture, there is a break in the bone, but it does not move the bone. These children are usually observed in the hospital for a brief amount of time, and can usually resume normal activities in a few days. No interventions are usually necessary.
Depressed skull fractures - This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull is actually sunken in from the trauma. Usually, this type of skull fracture requires surgical intervention to help correct the deformity.
Diastatic skull fractures - These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse with the growth of the child. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in newborns and older infants. These are fractures that occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse with the growth of the child. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in newborns and older infants.
Basilar skull fracture - This is the most serious type of skull fracture, and involves a break in the bone at the base of the skull. Children with this type of fracture frequently have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These children require close observation in the hospital.
There are many causes of head injury in children. The more common injuries are falls, motor vehicle accidents (where the child is either riding as a passenger in the car or is struck as a pedestrian), or a result of child abuse. The risk of head injury is high in the adolescent population and is twice as frequent in males than in females. Studies show that head injuries are more common in the spring and summer months when children are usually very active in outdoor activities such as riding bicycles, in-line skating, or skateboarding. The most common time associated with head injuries is late in the afternoon to early evening hours, and on weekends.
When there is a direct blow to the head, shaking of the child (as seen in many cases of child abuse), or a whiplash-type injury (as seen in motor vehicle accidents), the bruising of the brain and the damage to the internal tissue and blood vessels is due to a mechanism called coup-countercoup. A bruise directly related to trauma, at the site of impact, is called a coup lesion (pronounced COO). As the brain jolts backwards, it can hit the skull on the opposite side and cause a bruise called a countercoup lesion. The jarring of the brain against the sides of the skull can cause shearing (tearing) of the internal lining, tissues, and blood vessels that may cause internal bleeding, bruising, or swelling of the brain.
The full extent of the problem may not be completely understood immediately after the injury, but may be revealed with a comprehensive medical evaluation and diagnostic testing. The diagnosis of a head injury is made with a physical examination and diagnostic tests. During the examination, the physician obtains a complete medical history of the child and family and asks how the injury occurred. Trauma to the head can cause neurological problems and may require further medical follow up.
Learn more about head injuries.
A recent flurry of media attention about concussions has heightened awareness about their potentially serious short- and long-term effects—and raised concerns in young athletes, their parents and coaches. Bill Meehan, MD, primary care Sports Medicine fellow at Boston Children's Hospital's concussion clinic, discusses the topic.
What causes a concussion?
Concussions are mild traumatic brain injuries that occur after a rapid acceleration of the brain. This typically happens when a person is struck in the head, but it can also occur if an athlete is hit on the facemask or chest, causing the head to snap forward or backward.
What are the symptoms of a concussion?
Symptoms include headaches, nausea, vomiting and a sense of being out-of-it or feeling foggy. Most young athletes don't recognize their symptoms as a concussion. Parents can look for signs, like their child being slow to respond verbally, being off-balance and looking spaced-out or glassy-eyed. The bottom line is if you suspect your child has a concussion, he or she should see a doctor. It's critical that patients are evaluated after sustaining a concussion. It's very important that the patient isn't cleared to return to sports until normal brain function has returned—which we can assess through neurological testing—since a second concussion is more likely and, in rare cases, can be fatal.
Is there genuine cause for worry?
Most kids, if their concussions are managed properly and they don't go back into risky situations until they're recovered, will be fine. Typically, children fully recover from a sports-related concussion within 10 days and will regain normal brain function and do just as well at sports and school as they always did. However, some patients take months to recover completely, and children who get a second concussion before fully recovering from the first are at risk for serious, long-term problems.
What are the long-term problems?
The most common long-term problem is delayed or incomplete recovery. This can be seen after multiple concussions, or recurrent concussions, occurring prior to complete recovery from a previous concussion. Some rare situations get a lot of media attention, like second impact syndrome. This happens when a person isn't completely recovered from his first concussion and gets struck in the head again. For reasons we don't understand, they can get massive brain swelling. These patients die or live in a vegetative state.
Recently something called chronic traumatic encephalopathy has been described in pro athletes, like wrestlers and football players, who had multiple concussions and went on to have difficulty later in life with depression, memory and daily living activities. Biopsies revealed changes in their brains similar to Alzheimer's disease. The theory is that these concussions caused changes in their brains that altered their personalities and recognition. It’s brand new information and there are only a handful of cases, so there may be other things these athletes have in common in addition to concussions.
Who is at the greatest risk for long-term problems?
People who have already sustained a concussion are at greater risk for subsequent concussions. The effects are likely cumulative, so each causes more severe symptoms and requires longer recovery times. If a child has just one concussion, we probably won’t see a detectable change in his cognitive abilities. If he has multiple concussions, we often detect long-term changes in his abilities. Nobody knows what the magic number is when you start to see a long-term effect. Some say two, but we’ve treated athletes who've had five or six concussions and have seen no measurable difference.
How can you decrease the risk of getting a concussion?
Proper recovery from previous concussion is the best thing you can do. The other thing you can do is neck-strengthening exercises, which can help keep the head from snapping backward or forward during impact.
Do helmets help prevent concussions?
No, they weren't designed for that purpose. They are made to prevent catastrophic brain injury—which they're very effective at—so every athlete should have a new, properly fitted, undamaged helmet. But they won't decrease risk of concussion. Mouth guards have been proposed as decreasing concussion risk, but they don’t help either. Everyone should still wear them because they go a long way in preventing maxillofacial trauma, but they aren’t related to concussion risk.
How do you diagnose a concussion?
We take an athlete's history, conduct a physical examination, perform a standardized balance assessment and use computerized neuropsychological testing. Ideally, he'll have had a baseline test taken prior to his injury that we can use for comparison. That way we can test him until his scores match where they were before. We offer this baseline neuropsychological testing at Boston Children's and absolutely recommend parents get their child tested if he or she plays a high-risk sport, like ice hokey, football, rugby or soccer.
What's the treatment?
Physical and cognitive rest is the main treatment. We remove the child from athletics and other aerobic activity, then monitor his progress during his recovery, the length of which depends on the type of symptoms and number of his previous concussions. Other times, we treat symptoms with drug therapy. Before putting him back into contact sports, we repeat neuropsychological testing. If needed, we may refer patients to our Brain Injury Center.
How do you know when a child is recovered?
Typically, it takes 10 days to four weeks, but some never recover. That's rare, and those people tend to have multiple concussions or one due to a major force, like sledding into a tree or being in a car accident. If we have a child’s baseline neurological work-up taken before his injury, we know what his brain is capable of and know when he's back to baseline.
Learn more about concussions.
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On July 20, 2010, Massachusetts Governor Deval Patrick signed into law S796, An Act Relative to Safety Regulations for School Athletic Programs, which directs the Department of Public Health's Division of Violence and Injury Prevention to develop an interscholastic athletic Head Injury Safety Training program with the aim of reducing the potentially catastrophic impact of sports-related concussions.
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