Clinical scenario

Different emergency departments have different protocols/preferences in the way children with mild or minor head injury are investigated. Some prefer observation plus or minus plain skull radiographs, others use head scan as the first choice modality. The department you are currently working in uses plain radiology. You are concerned that in children with mild head injury with no abnormal neurology and no fracture seen on plain skull films there is a

tendency to be falsely reassured that intracranial injury (ICI) is unlikely.

Three part question

In [children with minor head injury] does [absence of skull fracture] predict [absence of ICI]?

Search strategy

Medline 1985–08/01 using the OVID interface. {(exp brain injuries/ or exp craniocerebral trauma/ or exp head injuries, closed/ or head trauma.mp or head injur$.mp or exp skull fractures/ or skull fracture$.mp) AND (exp child/ or exp adolescence/ or exp child, abandoned/ or exp child, exceptional/ or exp child, hospitalized/ or exp child, institutionalized/ or exp child of impaired parents/ or exp child, preschool/ or exp child, unwanted/ or exp disabled children/ or exp homeless youth/ or exp infant/ or exp only child/ OR child$.mp or exp pediatrics/ or pediatric$.mp or paediatric$.mp) AND (exp tomography scanners, x-ray computed/ or exp tomography, x-ray computed/ or tomography.mp or CT scan$.mp) AND (exp prospective studies/ or prospective.mp or prospectively.mp)} LIMIT to (human and English language and yr=1985–2001).

Search outcome

Altogether 194 papers were found, of which 187 were irrelevant or of insufficient quality to include. The remaining seven papers are shown in the table.

Comment(s)

Seven prospective papers were found. No consistent evidence exists to show that the presence or absence of skull fracture reliably predicts ICI. There is a suggestion that older children with skull fracture may have higher risk for ICI. Computed tomography was used to show isolated ICI (that is, no fracture seen), in 4%–15% of children with mild head injury (GSC=13). The significance of ICI in this group remains unclear, 1%–3% have neurosurgery implying that missed ICI from mild head injury can occasionally have severe consequences.

Clinical bottom line

The absence of skull fracture does not predict absence of ICI as seen on computed tomography. Computed tomography is therefore the imaging modality of choice if ICI is to be excluded in children with mild head injury.