Mild head injuries: A source of excessive radiography? (Analysis of a series and review of the literature)

The utility of post-traumatic skull X-rays.

“…This overwhelming majority of head injury attenders, in whom the presence or absence of a skull fracture cannot be determined, includes the majority (76%) of patients shown to have a skull fracture radiologically. Since demonstrating the presence of a skull fracture is of undoubted significance to clinicians (Briggs, 1974;Briggs et al, 1984;de Lacey et al, 1980;Galbraith, 1973Galbraith, , 1976Jennett & Miller, 1972;Jennett, 1980;Larsen & Koziol, 1979;Mendelow et al, 1983;Miller & Jennett, 1968;Sande et al, 1980), one must ask how else the fracture can be diagnosed other than radiologically. In fact, it is surprising, in view of the impossibility of making the diagnosis clinically in 99% of cases, that only about half of all A & E attenders with head injury undergo skull X-ray examination.…”

“…Radiologists often imply that because few skull X-rays show the presence of a skull fracture this investigation is of little value (Bell & Loop, 1971;Boulis et al, 1978;De Campo & Petty, 1980;de Lacey et al, 1980;Evans, 1977;Eyes & Evans, 1978;Masters, 1980;Phillips, 1979;Roberts & Shopfner, 1972;Royal College of Radiologists, 1980. However, a low positive yield from an investigation does not necessarily mean that such an investigation is worthless.…”

“…Medico-legal considerations are also often thought to contribute to unnecessary requests for skull X-ray, although the proportion of requests attributed to these reasons is very variable (Bell & Loop, 1971;Boulis et al, 1978;Cordon, 1981;Cummins, 1980;de Lacey et al, 1980;Eyes & Evans, 1978;Roberts & Shopfner, 1972;Royal College of Radiologists, 1980), but the only reasons for selecting patients for (skull) X-ray after injury are medical; if no medical reason exists, there can be no legal reason for an X-ray. It behoves doctors to agree the medical indications for a skull X-ray.…”

“…The opposing view, usually expressed by neurosurgeons and accident surgeons, is that plain skull films are indispensable in that they help to identify patients at risk from complications such as intracranial haematoma (Jennett, 1980;Galbraith, 1976;Galbraith, 1973;Mendelow et al, 1983;Briggs et al, 1984) or infection (Miller & Jennett, 1968;Jennett & Miller, 1972;Sande et al, 1980, Briggs, 1974, and may allow the identification of patients requiring admission who would otherwise be discharged (Jennett, 1980;Mendelow et al, 1983;Briggs et al, 1984) or, conversely, allow the safer discharge of patients who might otherwise be admitted (Jennett, 1980;Mendelow et al, 1983;Briggs et al, 1984). It has also been suggested that half or more of radiologically apparent skull fractures are missed by accident and emergency (A & E) staff (de Lacey et al, 1980;Gibson, 1983). The present article examines both the usefulness of skull X-rays and the accuracy of radiological diagnosis by A & E staff as well as suggesting which A & E attenders with head injury should be selected for X-ray.…”

Risk Factors in the Outcome of Children with Minor Head Injury

“…The usefulness of skull x-rays for the child with head injuries has been under question [29,[30][31][32], Feuerman et al [8] stated that skull x-rays are not necessary in the decision-making process for children with minor head injuries because management decisions can be based on careful neurological examination. Even though the infor mation obtained by having skull x-rays would not have altered the treatment of the patient, most studies con clude that the presence of skull fracture increases the probability of intracranial hematomas or subsequent neu rological deterioration [13,15,33.…”