Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation

doi:10.1016/j.jpedsurg.2010.12.019

Journal of Pediatric Surgery

Volume 46, Issue 7, July 2011, Pages 1342-1346

https://doi.org/10.1016/j.jpedsurg.2010.12.019 Get rights and content

Abstract

Purpose

The management of children presenting with an isolated skull fracture (ISF) posttrauma is highly variable. We sought to estimate the risk of neurologic deterioration in children with a Glasgow coma score (GCS) 15 and ISF to reduce unnecessary hospital admissions.

Methods

A retrospective review at a level I pediatric trauma referral center was conducted for patients with ISF on head computed tomography from 2003 to 2008. Patients were excluded for injury greater than 24 hours prior, GCS less than 15, intracranial pathology, significant fracture depression, or complex fractures involving facial bones or skull base.

Results

A total of 235 patients were identified with an ISF. The median age was 11 months, with falls accounting for 87% of the injuries. One hundred seventy-seven patients were admitted, and 58 patients were discharged from the emergency department after a period of observation (median, 3.3 hours). Median length of stay for those admitted to the hospital was 18.2 hours. One patient developed vomiting following overnight observation and a repeat computed tomography scan demonstrated a small extra-axial hematoma that required no intervention. The mean total costs for patients discharged from the emergency department were $291 vs $1447 for those admitted for observation (P < .001).

Conclusion

Patients with a presenting GCS of 15 and an ISF can be safely discharged from the emergency department after a short period of observation if they are asymptomatic and have a reliable social environment. This could result in significant savings by eliminating inpatient costs.

Section snippets

Methods

A retrospective review of children seen at a tertiary level I trauma center between January 1, 2003, and December 31, 2008, with a diagnosis of isolated linear (and minimally displaced) closed fractures of the skull vault was conducted. All skull fractures were diagnosed using computed tomography (CT). Patients with a diagnosis of closed skull fracture and a GCS of 15 were identified using the hospital trauma registry and an ED database. Patients were excluded from the study for the following

Results

A discharge diagnosis of skull fracture was identified in 1810 patients from January 2003 to December 2008. Two hundred thirty-five children met the inclusion criteria. Fracture location included parietal (110), occipital (72), frontal (28), temporal (10), and multiple bones (15). Patient age ranged from 4 days to 14 years (median, 11 months; Fig. 1). There were a diversity of mechanisms of injury, but falls predominated accounting for 87% of the injuries (Table 1). Seventy-one patients (30%)

Discussion

More than 600,000 ED visits per year in the United States are for the evaluation of children with head trauma. One percent to 2% of all children visiting an ED present with minor head injury, and of those children, less than 1% require neurosurgical intervention [2], [3].

Seventy-five percent of skull fractures in children are linear [7]. Skull fractures are identified in approximately 2% of all children following minor head trauma, but the incidence of skull fracture in children younger than 2

Conclusion

Based on this review, we feel that children who present with a GCS of 15 and a nondisplaced or minimally displaced ISF without ICI can be considered for discharge from the ED after a short period of observation if they are asymptomatic at the time of discharge and have a reliable social environment. Hospital admission is prudent for children with neurologic deficits, significant extracranial injuries, persistent vomiting, and suspected child abuse, or if parents are unreliable or unable to

References (14)

HaydelM.J. et al.
Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms
Ann Emerg Med
(2003)
SchutzmanS.A. et al.
Pediatric minor head trauma
Ann Emerg Med
(2001)
BrownL. et al.
Blunt pediatric head trauma requiring neurosurgical intervention: how subtle can it be?
Am J Emerg Med
(2003)
BeaudinM. et al.
Clinical algorithm and resource use in the management of children with minor head trauma
J Pediatr Surg
(2007)
GreenesD.S. et al.
Infants with isolated skull fracture: what are their clinical characteristics, and do they require hospitalization?
Ann Emerg Med
(1997)
KadishH.A. et al.
Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization?
Ann Emerg Med
(1995)
GruskinK.D. et al.
Head trauma in children younger than 2 years: are there predictors for complications?
Arch Pediatr Adolesc Med
(1999)

There are more references available in the full text version of this article.

Cited by (47)

Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomography Validation Study
2023, Annals of Emergency Medicine
We evaluated the emergency department (ED) providers’ ability to detect skull fractures in pediatric patients presenting with blunt head trauma.
This was a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomography (CT) validation study. Demographics and clinical characteristics were analyzed for pediatric patients. Radiologist interpretations of head CT imaging were abstracted and cataloged. Detection of skull fractures was evaluated through provider response to specific clinical decision instrument criteria (NEXUS or Canadian head CT rules) at the time of initial patient evaluation. The presence of skull fracture was determined by formal radiologist interpretation of CT imaging.
Between April 2006, and December 2015, 1,018 pediatric patients were enrolled. One hundred twenty-eight (12.5%) children had a notable injury reported on CT head. Skull fracture was present in most (66.4%) children with intracranial injuries. The sensitivity and specificity of provider physical examination to detect skull fractures was 18.5% (95% confidence interval 10.5% to 28.7%) and 96.6% (95.3% to 97.7%), respectively. The most common injuries associated with skull fractures were subarachnoid hemorrhage (27%) and subdural hematoma (22.3%).
Skull fracture is common in children with intracranial injury after blunt head trauma. Despite this, providers were found to have poor sensitivity for skull fractures in this population, and these injuries may be missed on initial emergency department assessment.
Pediatric basilar skull fractures from multi-level falls: A systematic review and retrospective analysis
2022, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
In this review, patients with isolated BSFs due to MLFs and benign neurological exams are at low risk for adverse outcomes and may be candidates for discharge with close outpatient follow-up [4,17]. This aligns with previously published work in this area [23,24]. In the studies that report MLF-specific data, rates of associated intracranial injuries like hemorrhage and CSF leak were varied.
Multi-level fall (MLF) accounts for 26.5%–37.7% of traumatic pediatric basilar skull fractures (BSFs). There is a dearth of information concerning recommendations for work-up, diagnosis, treatment, and otolaryngological follow-up of pediatric basilar skull fractures secondary to MLFs. Through a systematic literature review and retrospective review of an institution's trauma experience, we sought to identify clinical findings among pediatric MLF patients that indicate the need for otolaryngological follow-up.
A two-researcher team following the PRISMA guidelines performed a systematic literature review. PubMed, Web of Science, and EBSCO databases were searched August 16th^, 2020 and again on November 20th^, 2021 for English language articles published after 1980 using search terms Pediatric AND (fall OR “multi level fall” OR “fall from height”) AND (“basilar fracture” OR “basilar skull fracture” OR “skull base fracture” OR “skull fracture”). Simultaneously, an institutional trauma database and retrospective chart review was performed for all patients under age 18 who presented with a MLF to a pediatric tertiary care center between 2007 and 2018.
168 publications were identified and 13 articles reporting pediatric basilar skull fracture data and MLF as a mechanism of injury were selected for review. MLF is the most common etiology of BSF, accounting for 26.5–37.7% of pediatric BSFs. In the retrospective review, there were 180 cases of BSF from MLF in the study period (4.2%). BSF and fall height were significantly associated (p < 0.001), as well as presence of a CSF leak and fall height (p = 0.02), intracranial hemorrhage (ICH) (p = 0.047), and BSF fracture type (p < 0.001). However, when stratified by age, these associations were only present in the younger group. Of those with non-temporal bone BSFs (n = 71), children with hemotympanum (n = 7) were approximately 18 times more likely (RR 18.3, 95% CI 1.89 to 177.02) than children without hemotympanum (n = 64) to have hearing loss at presentation (28.6% vs. 1.6% of patients).
MLF is the most common cause of pediatric basilar skull fractures. However, there is limited information on the appropriate work-up or otolaryngologic follow-up for this mechanism of injury. Our retrospective review suggests fall height is predictive for BSF, ICH, and CSF leak in younger children. Also, children with non-temporal bone BSFs and hemotympanum may represent a significant population requiring otolaryngology follow-up.
Heads up!: Head trauma
2021, Pediatric Imaging for the Emergency Provider
Pediatric head trauma is a leading cause of injury and death in children. The difficulty in the pediatric population is identifying those patients with clinically important traumatic brain injuries while minimizing exposure to radiation. Computed tomography is the first-line imaging modality for patients with these suspected injuries. Magnetic resonance imaging is typically utilized as a secondary follow-up study, although its use as an acute study for traumatic brain injury is involving.
Traumatic brain injuries in a paediatric neurosurgical unit: A Queensland experience
2019, Journal of Clinical Neuroscience
Citation Excerpt :
Isolated non-displaced fractures carry a very low risk of deterioration or evolving injury [15], and are especially common in children under 2-years-old [6]. It is advocated that asymptomatic children with isolated skull fractures, and who are GCS 15 can be safely discharged [16]. Injury mechanisms that involve low kinetic energy suffered by children with non-operative pathology, or negative imaging following mild TBI could similarly be managed in an observation unit, discharged into a reliable social environment, or admitted for observation to the primary facility as appropriate.
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children with a broad injury spectrum and associated continuum in the level of care required. A dearth of data exists regarding children requiring inpatient neurosurgical admission following TBI. A retrospective study of children 0–16 years-old admitted to the neurosurgical unit of a level-1 paediatric trauma hospital in Queensland, Australia following TBI was conducted focusing on the demographics, clinical characteristics, and management of these patients to guide those involved in their management, and identify areas for improvement in injury prevention and trauma system management. Over 48 months, 671 patients were identified (62.6% male) with median age 5.0 years, the majority transferred from peripheral centres. Falls (47.2%) and traffic accidents (21.5%) were the most common mechanisms. Non-displaced skull fracture was the most common injury. Moderate or severe TBI (GCS 3–12) was seen in 14.8% of whom were more likely to require surgery, intensive care, or suffer polytrauma. Clinically significant TBI, defined as moderate/severe TBI, polytrauma, death, requiring neurosurgery, intensive care admission, intubation, or admission three or more nights was detected in 57.97% with higher rates in transferred patients (62.9%) versus primary presentations (50.6%). Mechanisms involving low kinetic forces especially low-height falls and children with non-surgical pathology were less likely to meet criteria for clinically significant TBI. Opportunity exists to optimise triage and transfer practices within the trauma network to minimise the economic and social implications of over-triage with many children requiring only brief observation.
Pediatric Cranial Reconstruction
2019, Facial Trauma Surgery: From Primary Repair to Reconstruction
Calvarial trauma in the pediatric population differs significantly from that seen in adults. Nonaccidental head trauma is the leading cause of death in infants less than 12 months of age, and must be ruled out during the initial patient evaluation. Unlike adults, most acute fractures can be managed nonoperatively, given the increased remodeling capacity of pediatric skulls. However, close follow-up is warranted in instances of conservative management; infants with linear skull fractures can develop a rare complication during early childhood as a result of accelerated calvarial expansion, known as growing skull fractures. While rare, this condition can result in severe and permanent neurological damage if diagnosis is delayed. Reconstructive options for calvarial defects need to take into account the growing skull, and need for long-term reliability and outcomes. As such, nonautologous techniques have a limited role in pediatric calvarial reconstruction, with most centers advocating for autologous techniques. Failure to appreciate the differences between children and adults when treating pediatric calvarial trauma will ultimately result in complications that can lead to severe morbidity or even death.
A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children
2018, Annals of Emergency Medicine
Citation Excerpt :
Consistent with guidance given by the Cochrane Collaboration, I2 heterogeneity is interpreted as potentially unimportant (0% to 19%), moderate (20% to 49%), substantial (50% to 79%), and considerable (>80%).15 We then repeated the primary analysis after excluding the single study exclusively using administrative data5 because medical records were not individually reviewed to confirm patient eligibility (eg, GCS score) and a few of the study participants may have previously been reported in another study (ie, overlap between participating institutions and study periods).4,16-19 To assess our secondary outcomes, we estimated additional pooled estimates and the I2 statistic, using the methods described above.
Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim is to quantify the frequency of short-term adverse outcomes of children with isolated skull fractures.
PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and gray literature were systematically searched to identify studies reporting on short-term adverse outcomes of children aged 18 years or younger with linear, nondisplaced, isolated skull fractures (ie, without traumatic intracranial injury on neuroimaging). Two investigators independently reviewed identified articles for inclusion, assessed quality, and extracted relevant data. Our primary outcome was emergency neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeated neuroimaging. Meta-analyses of pooled estimate of each outcome were conducted with random-effects models, and heterogeneity across studies was assessed.
Of the 587 studies screened, the 21 that met our inclusion criteria included 6,646 children with isolated skull fractures. One child needed emergency neurosurgery and no children died (pooled estimate 0.0%; 95% confidence interval [CI] 0.0% to 0.0%; I²=0%). Of the 6,280 children with known emergency department disposition, 4,914 (83%; 95% CI 71% to 92%; I²=99%) were hospitalized. Of the 569 children who underwent repeated neuroimaging, 6 had new evidence of intracranial hemorrhage (0.0%; 95% CI 0.0% to 9.0%; I²=77%); none required operative intervention.
Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns.

View all citing articles on Scopus

View full text

Original articleNeurologically intact children with an isolated skull fracture may be safely discharged after brief observation

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

J Pediatr Surg

Ann Emerg Med

Ann Emerg Med

Head trauma in children younger than 2 years: are there predictors for complications?

Arch Pediatr Adolesc Med

Original article
Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation