Aysha Habib  ( Department of Pathology, The Aga Khan University, Karachi. )
Amit Agrawal  ( Department of Surgery )
Suhas N Jajoo  ( Datta Meghe Institute of Medical Sciences )
S.R. Joharapurkar  ( Sawangi (Meghe), Wardha (India). )

Madam, The home can be a dangerous place for children; they spend most of their time there and it is where most accidents happen.¹ In case-1 four year female child presented with history of hit against table edge while playing at home. Following that she sustained partial avulsion of the scalp (Figure-1). There was no history of loss of consciousness, vomiting, convulsion ear or nasal bleed. The general and systemic examination was normal. There were no focal neurological deficits. Her skull X-ray was normal. In case-2, 1-1/2 year male child presented with history of fall from auto rickshaw and sustained avulsion injury of the scalp (Figure-2). He had transient loss of consciousness and two episodes of vomiting. His general and systemic examination was normal and there were no focal neurological deficits. CT scan showed linear fracture of occipital bone and there was no intracranial injury. In both the children, scalp flaps were sutured primarily after thorough cleaning with povidone-iodine, peroxide and normal saline (Figure-1 lower image and Figure-2). Both the patients made good recovery without any scalp defects. Avulsion injuries of the scalp are challenging to treat. If the periosteum is not intact and the status of local tissues does not allow local flap transposition, coverage of the exposed, denuded skull becomes a problem.² However in these two cases a thorough examination of the scalp revealed that there was no tissue loss and the scalp flaps could be approximated easily. The message is that after laceration wounds due to muscle insertion in the scalp it can retract to a great extent and if there is no tissue loss it is possible to suture the wound primarily without difficulty with good outcome. However it is the responsibility of adults to create play environments that are challenging for children but also safe to reduce the incidence and severity of injuries.³

Madam, The home can be a dangerous place for children; they spend most of their time there and it is where most accidents happen.¹ In case-1 four year female child presented with history of hit against table edge while playing at home. Following that she sustained partial avulsion of the scalp (Figure-1). There was no history of loss of consciousness, vomiting, convulsion ear or nasal bleed. The general and systemic examination was normal. There were no focal neurological deficits. Her skull X-ray was normal. In case-2, 1-1/2 year male child presented with history of fall from auto rickshaw and sustained avulsion injury of the scalp (Figure-2). He had transient loss of consciousness and two episodes of vomiting. His general and systemic examination was normal and there were no focal neurological deficits. CT scan showed linear fracture of occipital bone and there was no intracranial injury. In both the children, scalp flaps were sutured primarily after thorough cleaning with povidone-iodine, peroxide and normal saline (Figure-1 lower image and Figure-2). Both the patients made good recovery without any scalp defects. Avulsion injuries of the scalp are challenging to treat. If the periosteum is not intact and the status of local tissues does not allow local flap transposition, coverage of the exposed, denuded skull becomes a problem.² However in these two cases a thorough examination of the scalp revealed that there was no tissue loss and the scalp flaps could be approximated easily. The message is that after laceration wounds due to muscle insertion in the scalp it can retract to a great extent and if there is no tissue loss it is possible to suture the wound primarily without difficulty with good outcome. However it is the responsibility of adults to create play environments that are challenging for children but also safe to reduce the incidence and severity of injuries.³ [(f1)][(f2)]

1. Consumer Safety Unit. Home Accident Surveillance System, 19th Annual Report. London: Department of Trade and Industry, 1995.
2. Pitkanen JM, Al-Qattan MM, Russel NA. Immediate coverage of exposed, denuded cranial bone with split-thickness skin grafts. Ann Plast Surg. 2000; 45:118-21.
3. Alias A, Krishnapillai R, Teng HW, Latif AZA, Adnan JS. Head injury from fan blades among children. Asian J Surg 2005; 28:168-70.