What is the assessment and plan for an 8-year-old patient with a history of head and shoulder trauma due to a fall, presenting with initial left shoulder and ear pain, and current denial of any pain or symptoms?

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Last updated: March 26, 2025 • View editorial policy

Differential Diagnosis for 8-year-old with Head and Shoulder Injury

  • Single most likely diagnosis + Concussion or minor head injury: The child's fall from a height of 4 to 5 feet, landing headfirst, increases the risk of a concussion. The initial symptoms of left ear pain and swelling, without any reported loss of consciousness, nausea, or vomiting, suggest a mild head injury.
  • Other Likely diagnoses + Basilar skull fracture: Given the mechanism of injury (falling headfirst) and the presence of ear pain and swelling, a basilar skull fracture is a possible diagnosis, although less common. + Cervical strain or sprain: The fall could have caused strain or sprain to the neck muscles, which might have initially presented with neck pain, although the child currently denies any such pain. + Shoulder injury (e.g., clavicle fracture or shoulder sprain): The child initially reported left shoulder pain, which could be indicative of a fracture or sprain, especially given the point of impact.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.) + Epidural hematoma or other intracranial hemorrhage: Although the child denies loss of consciousness, nausea, or vomiting, these conditions can present subtly at first and deteriorate rapidly. The mechanism of injury increases the risk. + Cervical spine injury: Any fall from a height onto the head or neck warrants consideration of a cervical spine injury, which could be catastrophic if missed. + Temporal bone fracture: The presence of ear pain and swelling could also suggest a temporal bone fracture, which might have implications for hearing or facial nerve function.
  • Rare diagnoses + Ossicular disruption or other middle ear injuries: The trauma could potentially disrupt the ossicles in the middle ear, leading to hearing issues. + Carotid or vertebral artery dissection: Although rare, the mechanism of injury could potentially lead to dissection of these arteries, which would be a serious condition requiring prompt diagnosis and treatment.

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