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Injury Prevention and Safety

Child skull fracture



My daughter is 3 1/2 years old, and we were involved in an accident where the impact was on the front passenger side of the vehicle. She had a bruise on her right eye which led me to believe that her car seat may have shifted towards the impact of the wreck. However, she was taken to the hospital 4 days later when she developed black eyes and it was found that she had a skull fracture and some bleeding. The skull fracture was on her left side of her head, which is very puzzling. Is this possible? If so are there documented medical cases, and where could I find such cases or articles?


Yes, it is possible as a result of what is called the coup-contrecoup type of closed head injury. In this situation the brain suffers damage directly under the area of impact, but a second injury of equal or greater magnitude occurs directly opposite the point of contact. This occurs because the brain is suspended in the cranium or skull in cerebral spinal fluid with long nerve tracts extending from deep within the brain down into the spinal cord. When the head suffers a blow, the brain is first injured directly beneath the point of impact and then secondarily on the opposite side as the brain hurtles across the skull and slams into the  bony plates opposite the point of impact,  bouncing back yet again to the original site of injury. Children's bones are much more porous than adult bones and hence are far more likely to fracture than are adult bones.

In addition to the direct injury and secondary injury, such a severe blow also results in what is called diffuse axonal injury from the stretching and shearing of nerves in the brain as they move to the contrecoup injury site across the skull. This may result in abnormal brain function for sometimes lengthy periods as the nerves swell in response to the injury and then eventually heal. It is not possible to know what the exact outcomes of any injury will be, particularly for children, since their brains have more flexibility in healing (plasticity) and in the transfer of skills to other neurons than do the brains of adults. There is no way to predict how many cells are affected or their degree of recovery.

Your daughter's injury highlights the critical importance of using optimal restraint systems for children precisely in order to protect their brains, the most likely body part to be injured in a motor vehicle accident. Because children's heads are so large and heavy compared to the rest of their bodies, their heads function like bullets in an accident, pulling the child forward toward impact. Children should be in approved and properly installed car seats and booster seats until they are 80 pounds in weight AND 4 feet 9 inches in height. Research shows that up to 80% of child restraint systems are installed or used incorrectly.

If you are interested in reading more, enter coup-contrecoup injury or diffuse axonal injury or closed head injury into a search engine - these terms should lead you to additional information. I hope this information is helpful.

Related Resources:

Head and Brain Injuries (Medline Plus)

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Response by:

Mary M Gottesman, PhD, RN, CPNP, FAAN Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University