Linear Skull Fracture

Get CMELinear Skull FractureWe all know that traumatic brain injury is a significant concern when evaluating pediatric patients with head injury. Over the years, this concern has lead to significant shifts in imaging and management practices: some for the better and… others perhaps not. Fortunately, while assessing minor head injuries, the risk of medical radiation is now being better balanced with the appropriate concern for traumatic intracranial injury.  We know that not everyone benefits from a head CT.  Some events, are not minor though and some do cause injuries.  Certainly, if there is intracranial hemorrhage, we need to have heightened concern, but there is still a question as to what is beneficial to do for those who are found to have an isolated, linear skull fracture without other injuries.  Do these patients need further imaging? Do they benefit from transport to tertiary center? Do they even benefit from hospitalization? Let us look at the Isolated Linear Skull Fracture:

 

Head Injury: Basics

  • Physics works and kids aren’t coordinated.
    • The young child’s disproportionately larger head, decreased agility, and weaker muscles leads to the head striking surfaces in unprotected fashions more commonly than adults.
    • Gravity works (at least for the time being).
  • Most head injuries are mild, but still traumatic brain injury is a leading cause of death in children.
  • Fortunately, kids with a normal neurologic exam after head injury rarely require neurosurgical intervention! [Lyons, 2016; Schunk, 1996]

 

Skull Fracture

  • Skull fracture is the most common traumatic finding in kids with abnormal imaging after head injury.
    • Younger children (< 2 years of age, especially infants < 1 year of age) are particularly at risk for skull fracture.
    • Majority of skull fractures can be managed conservatively. [Bonfield, 2014; Mannix, 2013]
  • Some skull fractures are more concerning:
    • Skull fracture near major blood vessels
    • Depressed skull fracture
    • Presence of pneumocephalus
    • Presence of intracranial hemorrhage (of course)
  • Imaging
    • Plain radiographs
      • Can be useful, but, obviously, do not describe any intracranial complications.
      • In low risk patients, a normal skull x-ray may be helpful.
      • CT is generally preferred, especially for depressed fractures or diastatic skull fractures. [Kim, 2012]
    • Bedside Ultrasound
      • Has been used to define skull fracture in the ED. [Parri, 2013]
    • Rapid MRI
      • Rapid MRI protocols are useful in evaluation of hydrocephalus (see VP Shunt evaluation).
      • Rapid MRI has been shown to detect traumatic injuries with similar sensitivity and specificity as CT in followup imaging. May be what is done more commonly in the future. [Mehta, 2016]
    • CT
      • Generally considered the diagnostic method of choice, right now.
      • It is able to define the skull fracture and any associated  intracranial injuries.
      • Repeat Head CT, often performed, is not be beneficial in an asymptomatic kid with skull fracture. [Zulfigar, 2016; White, 2016; Hentzen, 2015]
      • May need to consider repeat imaging if there is neurological decline or concern for spinal fluid leakage. [White, 2016; Hentzen, 2015]
  • Dispostion:
    • Linear Skull Fracture, No Intracranial Hemorrhage on CT, and Normal Neurologic Exam;
      • Have a low risk for complications. [Blackwood, 2016; Addidoi, 2016; Arrey, 2015; Mannix, 2013]
      • These patients may be appropriate for discharge from the ED after brief period of observation in ED. [Addidoi, 2016;  Lyons, 2016; Rollins, 2010]
      • In the absence of concern for NAT, these patients also do not benefit from transfer to a level one trauma center. [White, 2016]
    • Depressed/Displaced skull fracture, fracture with altered mental status, or concern for NAT = Consult Neurosurgery and hopitalize. [Addioui, 2016]

 

NAT?

  • Sometimes, unfortunately, the skull fracture is not due to Gravity, but rather something more sinister.
  • Non-accidental trauma should always be considered, particularly in the young who cannot communicate effectively.
  • Things that should raise your concern for NAT include:
    • Vague explanation
    • Blaming another child or sibling, particularly one that isn’t developmentally able to do the feats described.
    • Inconsistent history
    • Delays in seeking care
    • Prior history of injuries
    • Bruising over areas without bony prominences
  • Always be mindful that there may be other occult injuries.
  • Obviously, if there is concern for NAT, even a simple linear skull fracture without intracranial hemorrhage should be hospitalized.

 

Moral of the Morsel

  • We (especially in the USA) likely admit too many children who do not benefit from the hospitalization.
  • A period of 4-6 hours (cuz that is the magic amount of time for everything) of observation in the ED and close outpatient follow-up may be most prudent.
  • A child with a normal neurologic exam and a linear, non-depressed skull fracture without intracranial hemorrhage does not benefit from:
    • Repeat imaging
    • Hospitalization for observation
    • Transfer to trauma center
  • Try to only hospitalize patient who will benefit from it.
    • Symptom management may require admission.
    • Concern for non-accidental trauma! requires admission.
    • Consider social dynamics – ensure that the child can  return to the hospital should she/he become sicker.

 

References

Lyons TW1, Stack AM2, Monuteaux MC2, Parver SL2, Gordon CR2, Gordon CD2, Proctor MR3, Nigrovic LE2. A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures. Pediatrics. 2016 Jun;137(6). PMID: 27244848. [PubMed] [Read by QxMD]

Addioui A1, Saint-Vil D2, Crevier L3, Beaudin M4. Management of skull fractures in children less than 1 year of age. J Pediatr Surg. 2016 Jul;51(7):1146-50. PMID: 26891833. [PubMed] [Read by QxMD]

Mehta H1, Acharya J2, Mohan AL3, Tobias ME3, LeCompte L2, Jeevan D3. Minimizing Radiation Exposure in Evaluation of Pediatric Head Trauma: Use of Rapid MR Imaging. AJNR Am J Neuroradiol. 2016 Jan;37(1):11-8. PMID: 26381555. [PubMed] [Read by QxMD]

Blackwood BP1, Bean JF2, Sadecki-Lund C3, Helenowski IB4, Kabre R5, Hunter CJ6. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. J Pediatr Surg. 2016 Apr;51(4):654-8. PMID: 26472656. [PubMed] [Read by QxMD]

Zulfiqar M1, Kim S1, Lai JP2, Zhou Y3. The role of computed tomography in following up pediatric skull fractures. Am J Surg. 2016 Aug 16. PMID: 27614418. [PubMed] [Read by QxMD]

White IK1, Pestereva E1, Shaikh KA1, Fulkerson DH2. Transfer of children with isolated linear skull fractures: is it worth the cost? J Neurosurg Pediatr. 2016 May;17(5):602-6. PMID: 26722759. [PubMed] [Read by QxMD]

Arrey EN1, Kerr ML1, Fletcher S1, Cox CS Jr1, Sandberg DI1. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr. 2015 Dec;16(6):703-8. PMID: 26339955. [PubMed] [Read by QxMD]

Hentzen AS1, Helmer SD2, Nold RJ3, Grundmeyer RW 3rd1, Haan JM4. Necessity of repeat head computed tomography after isolated skull fracture in the pediatric population. Am J Surg. 2015 Aug;210(2):322-5. PMID: 25907850. [PubMed] [Read by QxMD]

Orman G1, Wagner MW1, Seeburg D1, Zamora CA2, Oshmyansky A1, Tekes A1, Poretti A1, Jallo GI3, Huisman TA1, Bosemani T1. Pediatric skull fracture diagnosis: should 3D CT reconstructions be added as routine imaging? J Neurosurg Pediatr. 2015 Oct;16(4):426-31. PMID: 26186360. [PubMed] [Read by QxMD]

Bonfield CM1, Naran S, Adetayo OA, Pollack IF, Losee JE. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr. 2014 Aug;14(2):205-11. PMID: 24905840. [PubMed] [Read by QxMD]

Mannix R1, Monuteaux MC, Schutzman SA, Meehan WP 3rd, Nigrovic LE, Neuman MI. Isolated skull fractures: trends in management in US pediatric emergency departments. Ann Emerg Med. 2013 Oct;62(4):327-31. PMID: 23602429. [PubMed] [Read by QxMD]

Parri N1, Crosby BJ, Glass C, Mannelli F, Sforzi I, Schiavone R, Ban KM. Ability of emergency ultrasonography to detect pediatric skull fractures: a prospective, observational study. J Emerg Med. 2013 Jan;44(1):135-41. PMID: 22579023. [PubMed] [Read by QxMD]

Kim YI1, Cheong JW, Yoon SH. Clinical comparison of the predictive value of the simple skull x-ray and 3 dimensional computed tomography for skull fractures of children. J Korean Neurosurg Soc. 2012 Dec;52(6):528-33. PMID: 23346324. [PubMed] [Read by QxMD]

Rollins MD1, Barnhart DC, Greenberg RA, Scaife ER, Holsti M, Meyers RL, Mundorff MB, Metzger RR. Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg. 2011 Jul;46(7):1342-6. PMID: 21763832. [PubMed] [Read by QxMD]

Schunk JE1, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatr Emerg Care. 1996 Jun;12(3):160-5. PMID: 8806136. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Bryan says:

    Agreed that it sounds reasonable to discharge kids after observation with a linear fracture and normal ct, but ate you x-raying everyone with a minor head injury and scanning all the fractures? Or for someone who’s negative for the pecarn criteria, do they even need the xray?
    Thanks!

    • Sean Fox says:

      Bryan, thank you for your response!
      Simply put, no. Use PECARN and avoid unnecessary imaging low risk kids. What this post aimed at more was that if a non-depressed, linear skull fracture is found without complicating factors (ex, concern for NAT), then hospitalization merely for observation is not necessarily beneficial.
      Thank you,
      Sean

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