Impact of newly adopted guidelines for management of children with isolated skull fracture

A Systematic Review and Meta-Analysis on the Management and Outcome of Isolated Skull Fractures in Pediatric Patients

BACKGROUND

The impact of traumatic brain injury (TBI) on the pediatric population is profound. The aim of this study is to unveil the state of the evidence concerning acute neurosurgical intervention, hospitalizations after injury, and neuroimaging in isolated skull fractures (ISF).

MATERIALS AND METHODS

This systematic review was conducted in accordance with PRISMA guidelines. PubMed, Cochrane, Web of Science, and Embase were searched for papers until April 2023. Only ISF cases diagnosed via computed tomography were considered.

RESULTS

A total of 10,350 skull fractures from 25 studies were included, of which 7228 were ISF. For the need of acute neurosurgical intervention, the meta-analysis showed a risk of 0% (95% CI: 0-0%). For hospitalization after injury the calculated risk was 78% (95% CI: 66-89%). Finally, for the requirement of repeated neuroimaging the analysis revealed a rate of 7% (95% CI: 0-15%). No deaths were reported in any of the 25 studies.

CONCLUSIONS

Out of 7228 children with ISF, an almost negligible number required immediate neurosurgical interventions, yet a significant 74% were hospitalized for up to 72 h. Notably, the mortality was zero, and repeat neuroimaging was uncommon. This research is crucial in shedding light on the outcomes and implications of pediatric TBIs concerning ISFs.

The epidemiology of crib-related head injuries: A ten-year nationwide analysis

INTRODUCTION

Falls from cribs resulting in head injury are understudied and poorly characterized. The purpose of this study was to advance current understanding of the prevalence, descriptive characteristics of injury victims, and the types of crib fall-related head injuries (CFHI) using queried patient cases from the National Electronic Injury Surveillance System (NEISS) database.

METHODS

Using the US Consumer Product Safety Commission's System NEISS database, we queried all CFHIs among children from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of the incident, diagnoses, ED disposition, and sequelae were analyzed. The number of CFHI from all US EDs during each year was also collected from the database.

RESULTS

There were an estimated 54,799 (95% CI: 30,228-79,369) total visits to EDs for CFHIs between 2012 and 2021, with a decrease in incidence of approximately 20% during the onset of the COVID-19 pandemic (2019: 5616 cases, 2020: 4459 cases). The annual incidence of injuries showed no significant trend over the 10-year study period. An available subset of 1782 cases of head injuries from approximately 100 EDs was analyzed, and 1442 cases were included in final analysis. Injuries were sorted into three primary categories: unspecified closed head injury (e.g., closed head injury, blunt head trauma, or traumatic brain injury), concussion, or open head injury and skull fracture. Unspecified closed head injuries were the most common of all head injuries (95.4%, 1376/1442). Open head injuries (14/1442, 0.97%) and concussions 3.6% (52/1442, 3.6%) were rare. Most injuries involved children under the age of 1 (42.6%) compared to children who were 1, 2, 3, or 4-years old. About a fourth of patients had other diagnoses in addition to their primary injury including scalp/forehead hematomas, emesis, and contusions. Female patients were more likely to present with other diagnoses in addition to their primary head injury (Difference: 12.3%, 95% CI: 9.87%-15.4%, p < .0001).

CONCLUSION

Despite minimum rail height requirements set by the Consumer Safety Product Commission (CPSC), head injuries associated with crib falls are prevalent in the United States. However, most injuries were minor with a vast majority of patients being released following examination and treatment.

Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center

OBJECTIVE

Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy.

METHODS

Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020.

RESULTS

The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed.

CONCLUSIONS

Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.

Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study

BACKGROUND

Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation.

METHODS

We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years).

RESULTS

The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%).

CONCLUSION

One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.

Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review

OBJECTIVE

Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk.

METHODS

A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk.

RESULTS

A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup).

CONCLUSIONS

Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

Admission trends in pediatric isolated linear skull fracture across the United States

OBJECTIVE

Pediatric isolated linear skull fractures commonly result from head trauma and rarely require surgery, yet patients are often admitted to the hospital-a costly care plan. In this study, the authors utilized a national database to investigate trends in admission for skull fractures across the United States.

METHODS

Children younger than 18 years with isolated linear skull fracture, according to ICD-9 diagnosis codes in the Kids' Inpatient Database of the Healthcare and Utilization Project (HCUP), who presented between 2003 and 2016 were included. HCUP collected data in 2003, 2006, 2009, 2012, and 2016. Children with a depressed skull fracture, multiple traumatic injuries, and acute intracranial findings were excluded. Sample-level data were translated into population-level data by using an HCUP-specific discharge weight.

RESULTS

Overall, 11,355 patients (64% males) were admitted to 1605 hospitals. National admissions decreased from 3053 patients in 2003 to 1203 in 2016. The mean ± SD age at admission also decreased from 6.3 ± 5.9 years to 1.2 ± 3.0 years (p < 0.001). The proportion of patients in the lowest quartile of median household income increased by 9%, while that in the highest income quartile decreased by 7% (p < 0.001). Admission was generally more common in the summer months (June, July, and August) and on weekdays (68%). The mean ± SD hospital length of stay decreased from 2.0 ± 3.1 days to 1.4 ± 1.4 days between 2003 and 2012, and then increased to 2.1 ± 6.8 days in 2016 (p < 0.001). When adjusted for inflation, the mean total hospital charges increased from $13,099 to $21,204 (p < 0.001). The greatest proportion of admissions was in the South (35%), and the lowest was in the Northeast (17%). The proportion of patients admitted to large hospitals increased (59% to 72%, p < 0.001), which corresponded to a decrease in patients admitted to small hospitals (16% to 9%, p < 0.001). Overall, the total proportion of admissions to rural hospitals decreased by 6%, and that to urban teaching centers increased by 15% (p < 0.001). Since 2003, no child has undergone a neurosurgical procedure or died as an inpatient.

CONCLUSIONS

This study identified a general nationwide decrease in admissions for pediatric linear isolated skull fracture, but associated costs increased. Admissions became less common at smaller rural hospitals and more common at larger urban teaching hospitals. This patient population required no inpatient neurosurgical intervention after 2003.

Should ondansetron use be a reason to admit children with isolated, nondisplaced, linear skull fractures?

OBJECTIVE

Isolated, nondisplaced skull fractures (ISFs) are a common result of pediatric head trauma. They rarely require surgical intervention; however, many patients with these injuries are still admitted to the hospital for observation. This retrospective study investigates predictors of vomiting and ondansetron use following pediatric ISFs and the role that these factors play in the need for admission and emergency department (ED) revisits.

METHODS

The authors identified pediatric patients (< 18 years old) with a linear ISF who had presented to the ED of a single tertiary care center between 2008 and 2018. Patients with intracranial hemorrhage, significant fracture displacement, or other traumatic injuries were excluded. Outcomes included vomiting, ondansetron use, admission, and revisit following ED discharge. Both univariable and multivariable analyses were used to determine significant predictors of each outcome (p < 0.05).

RESULTS

Overall, 518 patients were included in this study. The median patient age was 9.98 months, and a majority of the patients (59%) were male. The most common fracture locations were parietal (n = 293 [57%]) and occipital (n = 144 [28%]). Among the entire patient cohort, 124 patients (24%) had documented vomiting, and 64 of these patients (52%) received ondansetron. In a multivariable analysis, one of the most significant predictors of vomiting was occipital fracture location (OR 4.05, p < 0.001). In turn, and as expected, both vomiting (OR 14.42, p < 0.001) and occipital fracture location (OR 2.66, p = 0.017) were associated with increased rates of ondansetron use. A total of 229 patients (44%) were admitted to the hospital, with vomiting as the most common indication for admission (n = 59 [26%]). Moreover, 4.1% of the patients had ED revisits following initial discharge, and the most common reason was vomiting (11/21 [52%]). However, in the multivariable analysis, ondansetron use at initial presentation (and not vomiting) was the sole predictor of revisit following initial ED discharge (OR 5.05, p = 0.009).

CONCLUSIONS

In this study, older patients and those with occipital fractures were more likely to present with vomiting and to be treated with ondansetron. Additionally, ondansetron use at initial presentation was found to be a significant predictor of revisits following ED discharge. Ondansetron could be masking recurrent vomiting in ED patients, and this should be considered when deciding which patients to observe further or discharge.

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

OBJECTIVE

Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.

METHODS

The authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.

RESULTS

The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).

CONCLUSIONS

The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

Pediatric nonoperative skull fractures: delayed complications and factors associated with clinic and imaging utilization

OBJECTIVE

Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up.

METHODS

The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging.

RESULTS

The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9-4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4-12, range 1-144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient's distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage.

CONCLUSIONS

Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients' subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.

Management of Isolated Skull Fractures in Pediatric Patients: A Systematic Review

OBJECTIVES

Isolated skull fractures (ISFs) in children are one of the most common emergency department injuries. Recent studies suggest these children may be safely discharged following ED evaluation with little risk of delayed neurological compromise. The aim of this study was to propose an evidence-based protocol for the management of ISF in children in an effort to reduce medically unnecessary hospital admissions.

METHODS

Using PubMed and The Cochrane Library databases, a literature search using the search terms (pediatric OR child) AND skull fracture AND (isolated OR linear) was performed. Three hundred forty-three abstracts were identified and screened based on the inclusion criteria: (1) linear, nondepressed ISF; (2) no evidence of intracranial injury; (3) age 18 years or younger; and (4) data on patient outcomes and management. Data including age, Glasgow Coma Scale score on arrival, repeat imaging, admission rates, need for neurosurgical intervention, and patient outcome were collected. Two authors reviewed each study for data extraction and quality assessment.

RESULTS

Fourteen articles met the eligibility criteria. Data including admission rates, outcomes, and necessity of neurosurgical intervention were analyzed. Admission rates ranged from 56.8% to 100%; however, only 8 of more than 5000 patients developed new imaging findings after admission, all of which were nonsurgical. Only 1 patient required neurosurgical intervention for a finding evident upon initial evaluation.

CONCLUSIONS

Pediatric ISF patients with a presenting Glasgow Coma Scale score of 15 who are neurologically intact and tolerating feeds without concern for nonaccidental trauma or an unstable social environment can safely be discharged following ED evaluation to a responsible caregiver.

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

BACKGROUND

The purpose of this study was to determine if a pediatric neurosurgical consultation for isolated linear skull fractures (ILSF) in pediatric patients with Glasgow Coma Scale (GCS) scores of ≥14 changed their management.

METHODS

A 10-year retrospective chart review at a Level 1 Pediatric Trauma Center was performed. Exclusion criteria were age > 18 years, open, depressed, or skull base fractures, pneumocephalus, poly-trauma, any hemorrhage (intraparenchymal, epidural, subdural, subarachnoid), cervical spine fractures, penetrating head trauma, and initial GCS scores ≤13. Primary outcomes were neurosurgery recommendations to change acuity of care, obtain additional imaging studies, and perform invasive procedures. Secondary outcomes were patient demographics, injury type, transfer status, admitting service, length of hospital stay, consult location, and clinical course.

RESULTS

There were 127 cases of ILSF meeting study criteria with an average age of 2.36 years. Unilateral parietal bone fracture was the most common injury (46.5%). Falls were the most common mechanism (81.1%). All patients received pediatric neurosurgical consultations within 24 h of hospital arrival. There were no neurosurgical recommendations to obtain additional imaging studies, change acuity of care, or perform invasive procedures.

CONCLUSIONS

Routine neurosurgical consultation in children with ILSF and GCS 14-15 does not appear to alter clinical management.

Development of the CIDSS2 Score for Children with Mild Head Trauma without Intracranial Injury

While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13-15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0-16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4-10.7), neurological Deficit (OR = 3.1; 95% CI 1.4-6.9), Seizure (OR = 3.7; 95% CI 1.8-7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0-37.3). Based on these results, the CIDSS₂ risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS₂ score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.

A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children

STUDY OBJECTIVE

Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim is to quantify the frequency of short-term adverse outcomes of children with isolated skull fractures.

METHODS

PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and gray literature were systematically searched to identify studies reporting on short-term adverse outcomes of children aged 18 years or younger with linear, nondisplaced, isolated skull fractures (ie, without traumatic intracranial injury on neuroimaging). Two investigators independently reviewed identified articles for inclusion, assessed quality, and extracted relevant data. Our primary outcome was emergency neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeated neuroimaging. Meta-analyses of pooled estimate of each outcome were conducted with random-effects models, and heterogeneity across studies was assessed.

RESULTS

Of the 587 studies screened, the 21 that met our inclusion criteria included 6,646 children with isolated skull fractures. One child needed emergency neurosurgery and no children died (pooled estimate 0.0%; 95% confidence interval [CI] 0.0% to 0.0%; I²=0%). Of the 6,280 children with known emergency department disposition, 4,914 (83%; 95% CI 71% to 92%; I²=99%) were hospitalized. Of the 569 children who underwent repeated neuroimaging, 6 had new evidence of intracranial hemorrhage (0.0%; 95% CI 0.0% to 9.0%; I²=77%); none required operative intervention.

CONCLUSION

Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns.

Soft-tissue evidence of head injury in infants and young children: is CT head examination justified?

AIM

To determine whether it is justified to undertake a computed tomography (CT) examination of the head in children under 1 year of age who present with a bruise, swelling, or laceration of >5 cm following head injury in children presenting to a paediatric accident and emergency (A&E) department in the northwest of England. Further aims were to determine whether there was any justification for performing a CT head examination for children with soft-tissue injuries measuring <5 cm, or for children >1 year with evidence of soft-tissue injury, but without any other concerning feature.

MATERIALS AND METHODS

Children <3 years of age presenting with soft-tissue evidence of head injury between May 2011 and Oct 2014 and who subsequently underwent head CT were retrospectively identified from radiology requests. The CT images and clinical notes were used to identify those with skull fracture or intracranial haemorrhage and to determine whether the child was subsequently admitted or discharged from A&E.

RESULTS

Eighty-five CT head examinations met the criteria for inclusion. Of these, 45 examinations demonstrated skull fractures and four examinations identified intracranial haemorrhage. Thirty-eight requests included soft-tissue evidence of head injury as the sole reason indicated for CT head examination. Of these, 22 examinations demonstrated skull fractures and one examination identified intracranial haemorrhage.

CONCLUSION

Soft-tissue evidence of head injury as the sole reason for CT head examination appears to be justified in the present patient population. Furthermore, this study suggests that CT head examination should also be considered for children with soft-tissue injuries of <5 cm and for children aged between 1 and 3 years if identification of a skull fracture would alter the child's management.

Diagnostic and Clinical Management of Skull Fractures in Children

OBJECTIVE

The indications of routine skull X-rays after mild head trauma are still in discussion, and the clinical management of a child with a skull fracture remains controversial. The aim of our retrospective study was to evaluate our diagnostic and clinical management of children with skull fractures following minor head trauma.

METHODS

We worked up the medical history of all consecutive patients with a skull fracture treated in our hospital from January 2009 to October 2014 and investigated all skull X-rays in our hospital during this period.

RESULTS

In 5217 skull radiographies, 66 skull fractures (1.3%) were detected. The mean age of all our patients was 5.9 years (median age: 4.0 years); the mean age of patients with a diagnosed skull fracture was 2.3 years (median age: 0.8 years). A total of 1658 children (32%) were <2 years old. A typical boggy swelling was present in 61% of all skull fractures. The majority of injuries were caused by falls (77%). Nine patients (14%) required a computed tomography (CT) scan during their hospital stay due to neurological symptoms, and four patients had a brain magnetic resonance imaging. Nine patients (14%) showed an intracranial hemorrhage (ICH; mean age: 7.3 years); one patient had a neurosurgery because of a depressed skull fracture. Nine patients (14%) were observed at our pediatric intensive care unit for a mean time of 2.9 days. The mean hospital stay was 4.2 days.

CONCLUSIONS

Our findings support previous evidence against the routine use of skull X-rays for evaluation of children with minor head injury. The rate of diagnosed skull fractures in radiographs following minor head trauma is low, and additional CT scans are not indicated in asymptomatic patient with a linear skull fracture. All detected ICHs could be treated conservatively. Children under the age of 2 years have the highest risk of skull fractures after minor head trauma, but do not have a higher incidence of intracranial bleeding. Neuroobservation without initial CT scans is safe in infants and children following minor head trauma and CT scans should be reserved for patients with neurological symptoms.

A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures

BACKGROUND AND OBJECTIVE

Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures.

METHODS

We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database.

RESULTS

We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%.

CONCLUSIONS

We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.

Transfer of children with isolated linear skull fractures: is it worth the cost?

OBJECTIVE Children with skull fractures are often transferred to hospitals with pediatric neurosurgical capabilities. Historical data suggest that a small percentage of patients with an isolated skull fracture will clinically decline. However, recent papers have suggested that the risk of decline in certain patients is low. There are few data regarding the financial costs associated with transporting patients at low risk for requiring specialty care. In this study, the clinical outcomes and financial costs of transferring of a population of children with isolated skull fractures to a Level 1 pediatric trauma center over a 9-year period were analyzed. METHODS A retrospective review of all children treated for head injury at Riley Hospital for Children (Indianapolis, Indiana) between 2005 and 2013 was performed. Patients with a skull fracture were identified based on ICD-9 codes. Patients with intracranial hematoma, brain parenchymal injury, or multisystem trauma were excluded. Children transferred to Riley Hospital from an outside facility were identified. The clinical and radiographic outcomes were recorded. A cost analysis was performed on patients who were transferred with an isolated, linear, nondisplaced skull fracture. RESULTS Between 2005 and 2013, a total of 619 pediatric patients with isolated skull fractures were transferred. Of these, 438 (70.8%) patients had a linear, nondisplaced skull fracture. Of these 438 patients, 399 (91.1%) were transferred by ambulance and 39 (8.9%) by helicopter. Based on the current ambulance and helicopter fees, a total of $1,834,727 (an average of $4188.90 per patient) was spent on transfer fees alone. No patient required neurosurgical intervention. All patients recovered with symptomatic treatment; no patient suffered late decline or epilepsy. CONCLUSIONS This study found that nearly $2 million was spent solely on transfer fees for 438 pediatric patients with isolated linear skull fractures over a 9-year period. All patients in this study had good clinical outcomes, and none required neurosurgical intervention. Based on these findings, the authors suggest that, in the absence of abuse, most children with isolated, linear, nondisplaced skull fractures do not require transfer to a Level 1 pediatric trauma center. The authors suggest ideas for further study to refine the protocols for determining which patients require transport.

Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly

BACKGROUND

Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly.

METHODS

We performed a single center 10year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention.

RESULTS

Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1week to 12.4years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p=0.7474, p=0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p<0.0001).

CONCLUSION

Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.

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

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.