A previously healthy ten-year-old girl was involved in a high speed motor vehicle accident (MVA) in which she was the belted front-seat passenger. The patient's teeth marks on the dashboard were evidence of a high-velocity impact. Her Glasgow Coma Score on scene was 13, and she was amnestic for the event. She was subsequently transported to the emergency room in full spinal precautions; on arrival she was hemodynamically stable with a Glasgow Coma Score of 14, complaining of neck and jaw pain. Neurological examination revealed impaired abduction of the right eye, with no other focal deficits. She had oral lacerations and bruising over the mandibles bilaterally.
Computed tomogram (CT) scan of the head was initially interpreted as normal, but on closer inspection demonstrated a 4mm retroclival hematoma (Figure 1). Sagittal CT through the upper cervical spine revealed the hematoma was epidural, bounded by the spheno-occipital synchondrosis superiorly and by the mid-body of the axis inferiorly (Figure 2). The odontoid was retroflexed (Figure 2). Bilateral mandibular fractures were also uncovered on facial imaging.