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A 9 month old boy fell from a bed onto an electric plug embedding the earth pin within his skull. The child did not lose consciousness and the mother removed the plug causing initial brisk bleeding. Examination revealed a 1 cm laceration to the left of the midline in the frontal area immediately behind the hairline. Neurological examination was normal. Radiography of the skull demonstrated a depressed skull fracture (fig 1). The wound was debrided under general anaesthesia with prophylactic antibiotic cover. The bone fragments were raised to reveal an intact dura. The fragments were washed and replaced and the pericranium, galea, and skin closed in separate layers. Postoperative recovery was uncomplicated with no long term sequelae at follow up.
A second child of 17 months attended the casualty department with an electric plug embedded in the left parietal area of his skull, again after falling out of bed. There had been no loss of consciousness and the child was alert and well. The live pin of the plug was almost completely embedded in the skull. Radiography demonstrated a depressed fracture beneath the pin (fig 2). Under general anaesthesia the plug was dismantled, the wound extended and debrided. The penetrating pin was removed and the fracture enlarged to reveal a 1cm laceration to the dura. There was no significant underlying brain injury. The dura was repaired, the bone fragments were replaced, and the wound closed in layers. Postoperative recovery was unremarkable and the child remained well at 12 month follow up.
Children under 5 years of age rarely sustain injury falling out of bed.1, 2 Most falls are onto carpeted floors that help cushion the impact. The small percentage of skull fractures that do occur in young children from short distance falls are generally uncomplicated, linear fractures which rarely have long term sequelae.3 However, the relatively soft skull of a child striking a hard object can result in a penetrating injury. These cases illustrate the potential hazards for young children from such seemingly innocuous household items. In case 1 involvement of the sagittal sinus could have resulted in air embolism or exsanguination on removal of the plug by the mother at home. If, as in case 2, the plug is still embedded at the time of presentation controlled removal in theatre is essential.
A review of 520 children admitted to the Royal Aberdeen Children's Hospital with a skull fracture over a 24 year period identified only 25 patients (4.8%) with an open injury. Road traffic accidents, falls, and golf club injuries4, 5 were the most common cases of these latter serious injuries. Fourteen patients required surgery, the remainder were managed by immediate wound toilet and penicillin based antimicrobial prophylaxis. Of the 14 patients who underwent exploration seven (50%) had a dural tear. Prophylactic anticonvulsants were not routinely prescribed and no child during the review period developed post-traumatic epilepsy or infective complications.
In conclusion, we highlight a previously unreported mechanism of open head injury in children resulting from unguarded electric plugs. When such a history is obtained skull radiography should be performed, despite an unremarkable clinical examination, to exclude an underlying skull fracture and dural tear.
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