We 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