Case by Brandon Ho MD, Children’s National PEM Fellow

An 11-year-old female presents with her mother with concern for wound infection. Three days ago, she was un-helmeted and fell off her bicycle and struck her head on the ground sustaining a forehead laceration. The mother states that patient initially blacked out for ~5 sec and was disoriented afterwards. No emesis. Per pictures of the injury, the laceration appears to be approximately 3 cm. She was brought to an outside ED where per mom, “staff placed sutures deep in the wound and then closed with skin glue”. No imaging was done, and no antibiotics were administered. The patient was discharged home in good condition.

The patient complained of intermittent photophobia and headache the day after the injury which has since resolved. She was seen by her PMD and received a tetanus shot. Per mom, the patient has been acting normal, tolerating PO, and has had no neurological deficits.

Today they present to our ED due to concerns about yellowish drainage from the wound with a foul odor and increasing facial swelling around the laceration, right eye, and nasal bridge. No fevers or red streaking from the wound. Today, the patient states she has no complaints and does not have any photophobia, headache, nausea, or pain.

PMH, PSH, Meds, Allergies: None

T37, HR 81, BP 112/64, RR20, 100% SaO2
General: Alert and oriented, cheerful, and in no distress.
HEENT: Forehead wound with skin glue intact and steri-strips over the wound. No dehiscence noted, no fluctuance or induration, no erythema. No foul odor or discharge noted. The area around the wound bed, right eye, and base of nasal bridge with minor swelling. PERRLA, EOMI. Orbits bones intact, no crepitus noted. Nasal bridge is straight and without crepitus but has associated tenderness to palpation. No evidence of septal hematoma. No hemotympanum.
Neuro: CN II-XII intact. Strength and sensation are intact throughout. Normal reflexes, coordination, and gait.

Given exam findings of increased swelling to forehead, right orbit, and nasal bridge, engaged in shared decision-making with mother about getting a maxillofacial CT to rule out any additional fracture. CT showed: Vertically oriented, mildly displaced right frontal bone fracture, approximately one cortex width separated, with overlying soft tissue swelling and hematoma. No acute intracranial finding appreciated.

Neurosurgery consulted. Mother relayed to neurosurgery that before repair she noted that the patient “had watery drainage coming from the wound”. The patient is now complaining of a return of photophobia. Neurosurgery states it is unlikely that the fracture tore through dura, however are concerned about the reports of watery drainage. Recommended obtaining labs (CBC, CRP, ESR), admission for observation for further drainage, and Infectious Disease consult to discuss antibiotic coverage for possible CSF leak. ID recommends lumbar puncture and meningitic dosing of ceftriaxone.

WBC 9.5, Hb 10.3, Hct 32.7, plt 316. ESR elevated 30. CRP 0.51