Pediatric Skull Fractures


Article Author:
Ailbhe McGrath


Article Editor:
Roger Taylor


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/2/2019 11:16:13 PM

Introduction

Head trauma can result in a skull fracture and is a common cause of morbidity and mortality in children. It is a regular presentation in the Paediatric Emergency Department (PED) and primary care. Children are more susceptible to head trauma and skull fracture than adults. A child's head size is approximately 18% of the total body surface area in infancy.  This will decrease to roughly 9% by adulthood.  Generally speaking, a child's skull is thinner and more pliable, thus providing less protection to the brain.[1][2][3]

Etiology

Causes of head injury and skull fracture can be separated into accidental and non-accidental injuries.  Commonly, head injuries are caused by a fall. Other causes can include motor vehicle accidents (MVA), sports-related injuries, or other direct blows to the head. Occasionally, depressed "ping-pong" fractures can occur in newborns due to injury at birth. A non-accidental injury is important for clinicians to identify in children who present with a head injury and subsequent skull fracture.  This is particularly important in the non-mobile infant. A meta-analysis of 12 studies of skull fractures in abuse have shown a skull fracture to be a positive predictive value of 20.1% in suspected or confirmed abuse cases.[4][5][6]

Epidemiology

Head injury is a very common presentation to the PED and is the most common cause of lethal trauma in children. Fortunately, the majority (80% to 90%) of head injuries can be classified as mild. Very few injuries are life-threatening or require neurosurgical intervention. The incidence of skull fracture in children following head injury ranges from 2% to 20%, and further epidemiological study is needed for more accurate incidence and prevalence rates. Skull fracture has been shown to be more common in children under the age of 2 years following head trauma. A fracture of the calvarium (skull cap) is more common than one at the base of the skull.[7]

Pathophysiology

The skull can be divided into the calvarium and the skull base. The calvarium is made up of the frontal, parietal, occipital, and temporal bones. The skull base is composed of the sphenoid, palatine, and maxillary bones along with portions of the temporal and occipital bones.

Types of Skull Fracture

LinearThis is the most common simple type. It is typically in the temporal or parietal area.

DepressedThis is usually caused by a direct blow to the head and requires a neurosurgical opinion. A depressed skull fracture can sometimes be referred to as a ping-pong fracture.

OpenAn open fracture carries a high risk of infection. 

BasalBasal fractures involve any of the bones of the base of the skull. Basal fractures are more complicated due to underlying structures such as cranial nerves and sinuses which can lead to hearing loss, facial paralysis, or decreased sense of smell. They also can pose a risk for meningitis.

DiastaticDiastatic fractures occur when there is a separation of the cranial sutures, most commonly with the lambdoid suture.

GrowingA growing fracture describes herniation of the brain through the broken dura following a skull fracture (often diastatic). It usually presents later and grows as the brain herniates through the gap, as a persistent swelling or pulsatile mass. It is uncommon.

History and Physical

A concise history can assist the clinician when determining whether a child presenting with a head injury has a high risk of a skull fracture or traumatic brain injury. 

Important factors include:

  • Time and presentation of injury: A delayed presentation should trigger concern and further questioning to determine if non-accidental injury is a possibility.
  • Mechanism of injury: Fall, dropped,  collision, blow to head, or MVA.
  • Whether the event was witnessed and if so by whom.
  • Further details about the injury: In the case of a fall, note the height of the fall and landing surface. In the case of an MVA, ask if the patient was ejected from the car or was rolled over and whether another passenger was killed, indicating a high-risk injury.
  • Condition immediately after the injury: Period of lost consciousness versus immediate cry.
  • Condition since injury occurred: Level of alertness, eating, vomiting, seizures.
  • Past medical history: Bony disorders such as osteogenesis imperfecta, bleeding disorders such as hemophilia, or if the child is on any medications.

Examination should include:

  • A trauma protocol with primary, secondary, and tertiary survey if major trauma suspected.
  • Glasgow coma scale (GCS) to assess the level of alertness. GCS may be less accurate in younger age groups, and a modified score should be used.
  • Examination of the head to palpate for a boggy swelling (may indicate an underlying fracture), a palpable fracture line, or lacerations. Head circumference should be measured if the fontanelle is open as an increasing head circumference can indicate intracranial bleeding or swelling.
  • Ear, nose, and throat examination to look for signs of basal skull fracture including haemotympanum, cerebrospinal fluid (CSF) or bloody otorrhoea or rhinorrhoea, Battle sign (ecchymosis on the mastoid process), or raccoon eyes (periorbital ecchymosis). Ring sign can be used to assess for CSF rhinorrhoea/otorrhoea that is mixed with blood. When the fluid is dropped onto filter paper, the CSF separates as a ring around the blood (central blood with a clear ring around it). However, ring sign is not specific to CSF as blood mixed with water, saline, and other mucous also will produce a ring sign.
  • Neurological and cranial nerve examination for signs of raised intracranial pressure including fundoscopy. Cranial nerve abnormalities such as visual defect, anosmia, hearing defect, facial numbness, or paralysis also can indicate a skull base fracture.
  • Head to toe examination assessing for bruising or other injuries in case of other traumatic injuries, or if suspicious, of non-accidental injury.

As a safeguarding procedure, the clinician always needs to carefully consider whether the described mechanism of injury is consistent with the developmental age of the child and the clinical findings.

Evaluation

 Skull fractures can be identified on plain radiography, CT, ultrasound, and MRI. Although practice varies throughout the literature, current guidance discourages the use of skull radiograph and advises the use of CT scan as the first-line investigation of choice if skull fracture is suspected. In few cases, a well, asymptomatic child with a localized head injury that is suspicious for fracture may be a candidate for skull x-ray instead of CT. The risks associated with CT scan in a child also should be considered. The younger the child, the greater the risk of malignancy later in life as a result of exposure to ionizing radiation. There also are associated risks with the sedation or anesthesia that may be required to perform a CT on a child.[8][9]

Multiple clinical decision rules exist to guide clinicians when a child with a head injury requires CT; the PECARN  (Paediatric Emergency Care Applied Research Network) head injury algorithm, the CATCH (Canadian Assessment for Tomography of Childhood Head Injury) rule and the CHALICE (Children's Head Injury ALgorithm for prediction of Clinically Important Events) rule. Signs of skull fracture that warrant investigation with CT include signs of basal skull fracture, a palpable fracture, a swelling, bruise or hematoma measuring greater than 5 millimeters or suspicion of a depressed skull fracture.

Ultrasound can be used to identify skull fractures in younger patients although it is not widely used and further studies are needed to assess its efficacy. MRI could prove a useful investigation without radiation exposure, but its use is also limited, due to availability in the acute setting.

Repeat CT imaging for patients with isolated skull fracture is not deemed necessary unless worsening clinical indicators develop.

Some centers have safeguarding policies in place to guide the need for further investigation for non-accidental injury in younger children and infants with a skull fracture. Routine skeletal surveys in this population with isolated skull fracture may only yield results in the non-mobile infants (less than 6 months) unless there are other indications. In these children, a skull radiograph may be required in addition to a CT as it has a higher sensitivity for old fractures.

Treatment / Management

Management of skull fractures depends on the location and type of fracture along with the presence (or absence) of underlying brain injury. Most skull fractures that are simple linear fractures without underlying brain injury and will require no intervention. Various practice patterns exist in regard to recommendations for observation periods or close outpatient followup. There are also variations whether skull fractures should be treated similar to concussions. In fact, one study has shown that most fractures requiring intervention do not necessarily require intervention for the fracture alone, but rather for an associated underlying injury. Younger patients, and symptomatic patients, should be admitted to the hospital for an observation period.  Variations to this practice are supported by multiple studies that have shown that asymptomatic children with simple fractures can be safely discharged from the emergency department. However, in each of these cases, a CT of the head had been performed to rule out an underlying brain injury.[10][11][12]

Frontal bone fractures are more likely to require neurosurgical repair. A depressed fracture usually requires intervention. Indications for a neurosurgical elevation of a depressed fracture include depression of 5 millimeters or more, dural injury, underlying hematoma, or gross contamination. An open fracture will likely require exploration and washout with antibiotic coverage. Basal skull fractures are usually managed conservatively unless there is persistent CSF leakage. A patient with a basal skull fracture should not have a nasogastric tube or nasal cannula. There is no evidence to support the role of prophylactic antibiotics in preventing meningitis, although, persistent CSF leak may increase the risk of meningitis.

Consultations

Neurosurgery

Trauma surgery

Neurointensivist

Pearls and Other Issues

Although head injury can lead to fatal brain injury and death, the majority of skull fractures are simple and can be managed conservatively. Head injury with a skull fracture, understandably, can generate huge parental anxiety, and clinicians need to be equipped with information to educate parents and allay fears. In addition, addressing concerns about safeguarding and non-accidental injury should be dealt with openly and in a professional manner. When discharge occurs directly from the emergency department, it should be to a safe environment with clear discharge instructions and return precautions.

Enhancing Healthcare Team Outcomes

an interprofessional approach should be considered in conjunction with trauma services, neurosurgery, general pediatrics, nurse practitioners, and social work.  The treatment depends on the severity of the injury and depression of the bone fragments. Close follow up is paramount to ensure safe outcomes.  Any child suspected to be a victim of nonaccidental trauma should be reported per state law.  The outcomes of skull fractures depend on many factors like a concomitant injury to other organs, presence of neurological deficit at the time of presentation, low GCS and need for mechanical ventilation.[13][14] (Level V)


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Pediatric Skull Fractures - Questions

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A 3-year-old girl presents to the emergency department after falling from a slide in a playground 3 hours ago. Her GCS is 15/15 and she has vomited once. On examination, she has a bruise behind her left ear. Her tympanic membrane is not visible due to wax. Which of the following bone is the most likely to be involved in this type of fracture?



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An 8-year-old girl is brought in by ambulance with multiple injuries following a collision with a motor vehicle while cycling without a helmet. Glasgow Coma Scale is 15/15. She has a palpable fracture on the back of her head in the left occipital area with an overlying 5mm laceration. CT (computed tomography) reveals a depressed fracture about 10 mm in depth and no obvious underlying brain injury. Which of the following is the next best step in the management of this patient?

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What is the most sensitive test used to make a diagnosis of skull fracture?



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What degree of depression in a skull fracture is deemed necessary for elevation by surgery?



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A trauma patient has a depressed skull fracture. Which of the following statements is TRUE?



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A 14-year-old boy presents to the emergency department with headache and vomiting. He was discharged 4 days ago after sustaining a basilar skull fracture while playing hockey. On presentation, his temperature is 38.6ºCelsius, heart rate 112 beats/minute, blood pressure 129/78 mmHg. He is pale and covering his eyes. What is the most likely organism causing his illness?



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A 6-year-old girl presents following head injury in a motor vehicle accident. She has bruising behind her left ear and blood is visualised behind her left tympanic membrane. What is the most likely diagnosis?



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Which of the following is true with regards to the management of skull fractures?



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According to the PECARN algorithm, the CATCH rule or the CHALICE rule, CT head is indicated for all of the following signs of skull fracture except which one?



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Which of the following is not a complication of skull fracture?



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A 7-year-old boy is brought in by ambulance following a fall from the first-floor window an hour ago into a flowerbed. He has bilateral lower limb injuries. His mother reports that he was unconscious for 2 minutes directly after the fall. Currently, his Glasgow coma score (GCS) is 15/15. Examination reveals a 2 cm laceration above his left ear with minimal swelling, no hemotympanum, and no obvious bruising. There is no history of vomiting or amnesia. Which of the following is the most appropriate next step in the management of this patient?



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A two-month-old girl is brought in by her mother after rolling off the kitchen table today while she was changing her nappy. She has a 2 cm hematoma above her left ear. Otherwise, the physical examination is entirely normal, and she appears to be a happy baby. She was born at full term and has been well until now. Which of the following is the next step in the management of this patient?



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Pediatric Skull Fractures - References

References

Karepov Y,Kozyrev DA,Benifla M,Shapira V,Constantini S,Roth J, E-bike-related cranial injuries in pediatric population. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2019 Apr 15;     [PubMed]
Harsh V,Vohra V,Kumar P,Kumar J,Sahay CB,Kumar A, Elevated Skull Fractures - Too Rare to Care for, Yet too Common to Ignore. Asian journal of neurosurgery. 2019 Jan-Mar;     [PubMed]
Campobasso CP,De Micco F,Bugelli V,Cavezza A,Rodriguez WC 3rd,Della Pietra B, Undetected traumatic diastasis of cranial sutures: a case of child abuse. Forensic science international. 2019 Mar 14;     [PubMed]
Hoz SS,Dolachee AA,Abdali HA,Kasuya H, An enemy hides in the ceiling; pediatric traumatic brain injury caused by metallic ceiling fan: Case series and literature review. British journal of neurosurgery. 2019 Feb 18;     [PubMed]
Andrew TW,Morbia R,Lorenz HP, Pediatric Facial Trauma. Clinics in plastic surgery. 2019 Apr;     [PubMed]
Donaldson K,Li X,Sartorelli KH,Weimersheimer P,Durham SR, Management of Isolated Skull Fractures in Pediatric Patients: A Systematic Review. Pediatric emergency care. 2019 Apr;     [PubMed]
Poorman GW,Segreto FA,Beaubrun BM,Jalai CM,Horn SR,Bortz CA,Diebo BG,Vira S,Bono OJ,DE LA Garza-Ramos R,Moon JY,Wang C,Hirsch BP,Tishelman JC,Zhou PL,Gerling M,Passias PG, Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database. International journal of spine surgery. 2019 Jan;     [PubMed]
Oleck NC,Dobitsch AA,Liu FC,Halsey JN,Le TT,Hoppe IC,Lee ES,Granick MS, Traumatic Falls in the Pediatric Population: Facial Fracture Patterns Observed in a Leading Cause of Childhood Injury. Annals of plastic surgery. 2019 Apr;     [PubMed]
Kommaraju K,Haynes JH,Ritter AM, Evaluating the Role of a Neurosurgery Consultation in Management of Pediatric Isolated Linear Skull Fractures. Pediatric neurosurgery. 2019;     [PubMed]
Harvell BJ,Helmer SD,Ward JG,Ablah E,Grundmeyer R,Haan JM, Head CT Guidelines Following Concussion among the Youngest Trauma Patients: Can We Limit Radiation Exposure Following Traumatic Brain Injury? Kansas journal of medicine. 2018 May;     [PubMed]
Tallapragada K,Peddada RS,Dexter M, Paediatric mild head injury: is routine admission to a tertiary trauma hospital necessary? ANZ journal of surgery. 2018 Mar;     [PubMed]
Azim A,Jehan FS,Rhee P,O'Keeffe T,Tang A,Vercruysse G,Kulvatunyou N,Latifi R,Joseph B, Big for small: Validating brain injury guidelines in pediatric traumatic brain injury. The journal of trauma and acute care surgery. 2017 Dec;     [PubMed]
Talari HR,Hamidian Y,Moussavi N,Fakharian E,Abedzadeh-Kalahroudi M,Akbari H,Taher EB, The Prognostic Value of Rotterdam Computed Tomography Score in Predicting Early Outcomes Among Children with Traumatic Brain Injury. World neurosurgery. 2019 Jan 21;     [PubMed]
Orru' E,Huisman TAGM,Izbudak I, Prevalence, Patterns, and Clinical Relevance of Hypoxic-Ischemic Injuries in Children Exposed to Abusive Head Trauma. Journal of neuroimaging : official journal of the American Society of Neuroimaging. 2018 Nov;     [PubMed]

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