Linear nondisplaced skull fractures in children: who should be observed or admitted?

Abstract

OBJECT In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed. METHODS After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children’s hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus. RESULTS Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7–395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2–43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit. CONCLUSIONS Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.

Evaluating the Role of a Neurosurgery Consultation in Management of Pediatric Isolated Linear Skull Fractures

“…Further evidence that a higher level of care may not be warranted comes from large studies that specifically examined transfers of pediatric ILSF to Level 1 Pediatric Trauma Centers [6, 12, 19, 20]. Similar to these studies, the vast majority of our patients were transfers from outside hospitals.…”

“…Our data answers a specific question that previous papers have alluded to, but not emphasized, in their results [6, 7, 10, 12, 14, 15]. To briefly summarize, Arrey et al [6] determined that there was no need to hospitalize 326 patients with ILSF with a median age of 19 months unless there was a pending nonaccidental trauma workup.…”

“…To briefly summarize, Arrey et al [6] determined that there was no need to hospitalize 326 patients with ILSF with a median age of 19 months unless there was a pending nonaccidental trauma workup. In addition, their study simply states, “…none required neurosurgical intervention.” In a similar 10-year time period to ours, Blackwood et al [7] found 71 ILSF cases among 163 patients with a median age of 1.17 years.…”

“…Isolated linear skull fractures (ILSF) are the most common type of pediatric skull fracture accounting for 85% of all skull fractures [5]. Despite numerous studies with large patient populations demonstrating that ILSF with Glasgow Coma Scale (GCS) scores of ≥14 have little risk for severe complications [3, 6-12], management of pediatric ILSF commonly includes admission and routine pediatric neurosurgical consultation. Our objective was to examine changes in management that arose from a pediatric neurosurgery consultation in pediatric patients with ILSF and GCS scores ≥14.…”

Linear fractures of the cranium: follow-up and management results of 442 cases

“…However, it is controversial whether performing follow-ups of these cases by hospitalizing them is cost-effective [8][9][10]. It has been reported that the number of cases having isolated fractures that require neurosurgical intervention is very low and mortality is <0.1% [7,10].…”