Evaluation of isolated skull fractures in children.

BACKGROUND

The Brain Injury Guidelines (BIG) was recently adapted to pediatric patients by developing a pediatric-specific risk stratification algorithm, BIG for Kids (kBIG).(1) Children differ from adults in injury patterns and have a higher prevalence of isolated skull fractures without intracranial hemorrhage (ICH). Given the frequency of this injury pattern, a distinct kBIG 0 category was created. This study aimed to better characterize isolated skull fractures in children. We hypothesized that these fractures carry a low risk of ICH development or neurosurgical intervention.

METHODS

We conducted a retrospective cohort study of pediatric patients (<18 years) with isolated skull fractures treated at a Level 1 pediatric trauma center from January 2018 to April 2024. Data collected included demographics, injury characteristics, location of fracture, repeat head CT, and neurosurgical intervention. Fractures were classified as nondisplaced, minimally displaced (< one cranium width), or displaced (≥ one cranium width).

RESULTS

Among 431 children, 63 % had nondisplaced, 27 % minimally displaced, and 10 % displaced fractures. Fracture locations most commonly involved the parietal, frontal, and occipital bones. ICH progression occurred in six patients (1.4 %), all with low Glasgow Coma Scale rating (GCS) or suspected hemorrhage. Nineteen patients (4.4 %) required neurosurgical intervention: six had GCS <15, and 13 had displaced fractures requiring fracture elevation. Fracture location was nonsignificant. No patient with a normal neurologic exam and a nondisplaced or minimally displaced fracture required surgery.

CONCLUSION

Children with isolated, nondisplaced or minimally displaced skull fractures and normal neurological exams had excellent outcomes. These patients do not require repeat imaging or neurosurgical consultation.