Indications for computed tomography use and frequency of traumatic abnormalities based on real-world data of 2405 pediatric patients with minor head trauma

[Diagnosis and Treatment in frontobasal fractures]

Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.

Investigation of clinical findings and CT scan in children with minor head trauma

BACKGROUND

The most common cause of death or severe impairment in children older than one-year-old is traumatic brain injury (TBI). Assessing TBI in children with minor head trauma (MHT) using clinical findings from history-taking and a physical exam is crucial to minimizing unnecessary brain CTs and more accurately predicting TBI. We aimed to evaluate the findings of brain CT scans in children with mild head trauma and their relationship with clinical signs and symptoms to avoid unnecessary interventions in many children with MHT.

METHODS

This cross-sectional-analytical study was performed to evaluate the findings of brain CT scans in children with MHT and their relationship with clinical signs and symptoms that were referred to Poursina Hospital in Rasht in the first half of 2021. Children were divided into two age groups: under two years and 2-12 years, and analyzed separately. Initially, a list containing all demographic information, patients' clinical signs, and symptoms were prepared. The collected data were then analyzed using SPSS software version 26.

RESULTS

According to the results, the mean age of patients was 66.01 months and 88 were boys (56.4%). The most common mechanism of injury was falling from a height. Most patients had isolated head injuries. Among the accompanying injuries, facial injuries were the most common. Among the clinical factors studied, cranial fracture on CT scan and GCS less than 15 were significantly associated with the occurrence of traumatic brain injury on CT scan. In addition, cranial fracture on CT scan, injury severity, and history of vomiting had the highest positive predictive value, respectively.

CONCLUSION

Standard history and clinical examination are sufficient to identify high-risk cases of pediatric head injuries. GCS is the most important risk factor for pediatric MHT. Requesting a CT scan is not recommended without these risk factors.

Pediatric basilar skull fractures from multi-level falls: A systematic review and retrospective analysis

OBJECTIVE

Multi-level fall (MLF) accounts for 26.5%-37.7% of traumatic pediatric basilar skull fractures (BSFs). There is a dearth of information concerning recommendations for work-up, diagnosis, treatment, and otolaryngological follow-up of pediatric basilar skull fractures secondary to MLFs. Through a systematic literature review and retrospective review of an institution's trauma experience, we sought to identify clinical findings among pediatric MLF patients that indicate the need for otolaryngological follow-up.

METHODS

A two-researcher team following the PRISMA guidelines performed a systematic literature review. PubMed, Web of Science, and EBSCO databases were searched August 16th^, 2020 and again on November 20th^, 2021 for English language articles published after 1980 using search terms Pediatric AND (fall OR "multi level fall" OR "fall from height") AND ("basilar fracture" OR "basilar skull fracture" OR "skull base fracture" OR "skull fracture"). Simultaneously, an institutional trauma database and retrospective chart review was performed for all patients under age 18 who presented with a MLF to a pediatric tertiary care center between 2007 and 2018.

RESULTS

168 publications were identified and 13 articles reporting pediatric basilar skull fracture data and MLF as a mechanism of injury were selected for review. MLF is the most common etiology of BSF, accounting for 26.5-37.7% of pediatric BSFs. In the retrospective review, there were 180 cases of BSF from MLF in the study period (4.2%). BSF and fall height were significantly associated (p < 0.001), as well as presence of a CSF leak and fall height (p = 0.02), intracranial hemorrhage (ICH) (p = 0.047), and BSF fracture type (p < 0.001). However, when stratified by age, these associations were only present in the younger group. Of those with non-temporal bone BSFs (n = 71), children with hemotympanum (n = 7) were approximately 18 times more likely (RR 18.3, 95% CI 1.89 to 177.02) than children without hemotympanum (n = 64) to have hearing loss at presentation (28.6% vs. 1.6% of patients).

CONCLUSIONS

MLF is the most common cause of pediatric basilar skull fractures. However, there is limited information on the appropriate work-up or otolaryngologic follow-up for this mechanism of injury. Our retrospective review suggests fall height is predictive for BSF, ICH, and CSF leak in younger children. Also, children with non-temporal bone BSFs and hemotympanum may represent a significant population requiring otolaryngology follow-up.