Elsevier

Annals of Emergency Medicine

Volume 30, Issue 3, September 1997, Pages 253-259
Annals of Emergency Medicine

Infants With Isolated Skull Fracture: What Are Their Clinical Characteristics, and Do They Require Hospitalization?,☆☆,

Data from 34 of our study subjects were presented in abstract form at the Ambulatory Pediatric Association Annual Meeting, May 1995.
https://doi.org/10.1016/S0196-0644(97)70158-6Get rights and content

Abstract

Study objective: We sought to identify the historical factors and physical examination findings typical of infants who have sustained isolated skull fracture (ISF)—in the absence of associated intracranial injury—after head trauma. We also assessed the risk of clinical deterioration (and therefore the need for inpatient observation) in infants with ISF. Methods: We conducted a retrospective analysis of all patients younger than 2 years admitted to a tertiary care pediatric hospital with a diagnosis of ISF over a 3-year period. Results: During the study period, 101 infants with radiographically proven ISF were admitted to the hospital. Falls were the most common reported mechanism of injury (n=90 [89%]). Many falls involved short distances: 18 patients (18%) fell less than 3 feet. Nonaccidental trauma was suspected in only 10 patients (10%). Seventy-two patients (71%; 95% confidence interval [CI], 61%, 79%) had at least one of the clinical signs considered potential indicators of serious head injury: initial loss of consciousness, seizures, vomiting, lethargy, irritability, depressed mental status, and focal neurologic findings. In 97 patients (96%;95% CI, 89%, 98%), local findings of head injury (palpable fracture, soft-tissue swelling, or signs of basilar skull fracture) were noted on physical examination. None of the patients (0%; 95% CI, 0%, 3%) demonstrated clinical decline during hospitalization. All were neurologically normal on discharge. Conclusion: A diagnosis of ISF should be considered even in infants with minor mechanisms of head injury who appear well. However, infants with ISF rarely present without local signs of head injury on physical examination. If no other specific clinical concerns necessitate hospital admission, infants with ISF who have reliable caretakers may be considered for discharge home. [Greenes DS, Schutzman SA: Infants with isolated skull fracture: What are their clinical characteristics, and do they require hospitalization? Ann Emerg Med September 1997;30:253-259.]

Section snippets

INTRODUCTION

Historically, screening for skull fractures has been performed in head-injured patients as a means of identifying patients at risk for intracranial injury.1, 2 Older guidelines called for hospitalization and observation of any patient with skull fracture resulting from head trauma.1, 2 As computed tomography (CT) has become widely available as a more definitive measure of intracranial injury, the significance of skull fractures in older children and adults has been called into question. Most

MATERIALS AND METHODS

The setting for the study was Boston Children's Hospital, a 300-bed tertiary care pediatric hospital that serves as a Level I pediatric trauma center and has an annual ED volume of 50,000.

We conducted a retrospective analysis of all children admitted to Children's Hospital between January 1, 1992, and December 31, 1994, who met the following criteria: (1) 24 months or younger, (2) no underlying condition that would make fracture more likely (eg, osteogenesis imperfecta), (3) diagnosis of skull

RESULTS

One hundred one infants younger than 2 years were admitted to Children's Hospital with radiographically proven ISF during the study period. The mean age of these patients was 7.3±5.1 months (range, 2 weeks to 23 months). Ninety-one of the patients (90%) were younger than 1 year.

Thirty-nine of the patients (39%) were girls, 62 (61%) boys. Twenty-nine of the patients (29%) were evaluated first in our ED, and 72 (71%) were referred from another institution after the skull fracture was diagnosed.

DISCUSSION

The data from our series help clarify several issues about infants with ISF. Specifically, our study has been able to demonstrate that (1) infants may sustain ISF—even depressed or multiple fractures—as a result of what, by history, are minor mechanisms of injury; (2) although infants with ISF may appear generally well, the vast majority have some local findings on head examination; and (3) infants with ISF have a very low risk of clinical deterioration.

We have found ISF to be a common reason

Acknowledgements

We thank Dr Karen Gruskin for her help in identifying study subjects and Dr Gary Fleisher for his thoughtful review of the manuscript.

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    From the Division of Emergency Medicine, Children's Hospital, Boston, MA.

    ☆☆

    Reprint no.47/1/83931

    Address for reprints: David S Greenes, MD, Division of Emergency Medicine, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115

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