The diversity of complaints and presentations in the ED keeps us on our toes and requires our continued vigilance. It is not uncommon for me to say, “I did not know that that could happen” during a shift. While we are often concerned about missing the subtle presentation of a dramatic illness (ex, Malignancy, Inflammatory Bowel Disease, Congestive Heart Failure), occasionally, a benign condition presents dramatically. Syncope, for example, is a dramatic presentation, but many times is related to benign conditions. In fact, Hair-Grooming may lead to Syncope. With that in mind, let us quickly consider another interesting phenomena that Hair-Grooming may lead to – Subgaleal Hematoma from Hair Braiding:

Subgaleal Hematomas

• The scalp is complex and composed of 5 layers! [Vu, 2004]

• The layers include (from superficial to deep): [Vu, 2004]
  • Skin
  • Connective Tissue
  • Galea Aponeurotica
  • Loose Areolar Tissue
  • Periosteum

• These layers may be disrupted from trauma (minor or major) and this leads to fluid collection / hematoma formation. [Edmondson, 2016; Onyeama, 2009; Vu, 2004]
  • Caput Succedaneum
    • Between Skin and Galea
    • Soft tissue edema or serosanguinous fluid, often related to birth.
  • Subgaleal Hematoma
    • Between Galea and Periosteum
    • Above the periosteum and can cross suture lines.
    • May extend anteriorly to the orbits and posteriorly to the neck.
    • In neonates, this large potential space can accommodate enough blood to lead to hemodynamic compromise!
  • Cephalohematoma
    • Between periosteum and Cranium
    • Restricted to the subperiosteal space and does not cross suture lines.

• The subaponeurotic space is different in young children: [Edmondson, 2016; Vu, 2004]
  • Tends to be more vascular with lots of small emissary veins
  • Skin is thinner, less protective

Subgaleal Hematomas and Minor Injury

• Subgaleal hematomas typically occur during the neonatal period. [Edmondson, 2016; Onyeama, 2009; Vu, 2004]
  • Most associated with birth.
  • Often in the parietal and frontal regions.

• More rarely seen in older children, but related to: [Edmondson, 2016; Onyeama, 2009; Vu, 2004; Raffini, 2004]
  • Skull fractures (accidental and non-accidental trauma)
  • Bleeding disorders (ex, von Willebrand) [Raffini, 2004]
  • Tangential or radial forces applied to scalp
    • Abrupt Hair Pulling (ex, fighting or non-accidental trauma)
    • Vigorous Hair Braiding and/or Grooming

• Present with:
  • Bogginess that typically develops insidiously (can over be several days) [Onyeama, 2009; Vu, 2004]
  • Older children may complain of headache as well

• Complications are rare, but can occur:
  • Extension of hematoma to orbit
    • Subsequent leakage of blood through the galeal attachments to the orbital ridges
    • Leads to proptosis and ocular emergencies.
  • Tissue compromise / necrosis

Subgaleal Hematoma Management

• Subgaleal Hematoma will typically resolves without therapy. [Edmondson, 2016]
  • Natural history is benign provided no ominous underlying etiology (ex, abuse, bleeding disorder).
  • May need intervention if: [Raffini, 2004]
    • Unremitting headache
    • Large volume, impending scalp necrosis
    • Hemodynamic instability (in neonates)
    • Concurrent infection

• Subgaleal Hematoma may be due to benign cause, but consider the other issues: [Edmondson, 2016; Onyeama, 2009; Vu, 2004; Raffini, 2004]
  • Why is there such easy bleeding?
    • Check CBC and Coags.
    • If history of easy bruising / bleeding or a concerning family history, consider screening for more specific bleeding disorders.
      • Bleeding time, von Willebrand antigen, ristocetin cofactor
      • Factor VIII level
  • Don’t underestimate the potential for trauma that is more significant.
    • High risk for underlying skull fractures.
    • Have a low threshold for cranial imaging.

Moral of the Morsel

• Hematomas come from Trauma! Don’t overlook the potential for NAT.
• If it was a minor event, why did it bleed so much? Consider bleeding disorders in older children.
• Not all hematoma are due to ominous etiologies. If the evaluation is reassuring and the story fits an etiology due to hair-braiding / grooming, that may be the cause (but I would still makes sure there is no occult fracture).

References