Subgaleal Hemorrhage Secondary to Child Physical Abuse in a 4-Year-Old Boy

Subgaleal hemorrhage is commonly described in the neonatal population but is a rare injury in young children and adolescents. Though infrequently seen, it can follow blunt head trauma or hair pulling. This case report details a 4-year-old African American boy with massive subgaleal hemorrhage and bilateral periorbital swelling and ecchymosis as a result of hair pulling in the setting of child physical abuse. The patient was evaluated in the emergency department for swelling of his scalp several hours after reportedly bumping his head on a chair. He was discharged home after a head computed tomography only confirmed soft tissue hematoma. The following morning, the findings progressed and he returned to the emergency department. He was triaged as a trauma and initially evaluated by the emergency physician, pediatric trauma surgeon, and pediatric neurosurgeon. Head computed tomography scan confirmed diffuse scalp edema without skull fracture or intracranial pathology. The child abuse specialty service was consulted for suspected child physical abuse. Their examination revealed numerous scattered bruises on the trunk and thighs, several of which were patterned. Local police investigation resulted in the patient's grandfather confessing to striking the patient with a belt and picking him up from the ground by his hair, the latter of which is a mechanism consistent with the patient's dramatic scalp and facial findings. The authors encourage consultation by a specialist in child abuse pediatrics for subgaleal hemorrhage and/or raccoon eyes in the presence of minor trauma, as well as thorough head-to-toe skin examination for all children presenting with injuries.