When children hit their heads it can be scary for parents and providers alike. But given the numbers, it might not make sense to reflexively admit.
You are examining a 7 month-old baby boy who fell off the changing table onto a hard tiled floor at day care this morning. He cried immediately and vomited a few times. Several hours have passed since the fall and now he is behaving normally. He has fed in the waiting room with no emesis. He has a normal and non-focal neurological exam. He has a left parietal scalp hematoma but no other apparent injuries. Nothing in the story has raised concerns about non-accidental trauma. The boy is an otherwise healthy infant with no significant history. A head CT was obtained which demonstrates a non-displaced parietal linear skull fracture but no other findings. Your resident has phoned in an admission for observation. After all, that is what we usually do. But should we?
According to the CDC, the rates of ED visits for traumatic brain injury have increased from 2001-2002 to 2009-2010. Children aged 0 to 4 years had the highest rate of any age group. In 2007-2008, the rate of TBI-related ED visits in this age group was 1374 per 100,000. In 2009-2010 it was 2193.8 per 100,000, a 50% increase.Overall, males, ages 0 to 4 years have the highest rates of TBI-related ED visits, hospitalizations and deaths compared to other groups in the US [1].
Most children with isolated linear skull fractures are admitted to the hospital for observation and monitoring. A retrospective study in Houston, Texas looked at 326 patients with isolated non-displaced linear skull fractures. The median age was 19 months but ages ranged from 2 weeks to 15 years. Only 17% were discharged from the ED, the rest were admitted to the hospital floor or placed in 23-hour observation. No patient had a positive neurological exam and none required a neurosurgical intervention [2]. A retrospective review of pediatric head trauma patients in Chicago, Illinois looked at 71 patients with isolated skull fractures. Their ages ranged from 1 week to 12.4 years. 77.5 % were admitted for neurological observation and none required a neurosurgical procedure [3]. In a multicenter study of management trends in US pediatric EDs, almost 4,000 children younger than 19 years were seen for isolated skull fractures. 78% of these patients were admitted, 85% discharged the next day and 95% discharged within 2 days. Only one patient required a neurosurgical procedure [4].
One of the largest studies of head injury in children is the Pediatric Emergency Care Applied Research Network (PECARN) study. They looked at 43, 904 children with blunt head injury across multiple sites. Of these, 11,035 were less than 2 years of age. In their sample 350 patients had skull fractures but no other abnormalities identified. 201, or about 57% were hospitalized, the rest were discharged from the ED. No one needed a neurosurgical intervention [5].
As physicians, we are very anxious about skull fractures, as evidenced by the high rate of admissions. Maybe what we need is a better understanding of which skull fractures are high risk so we can avoid admitting those unlikely to require any intervention. A study addressing this very issue looked at 897 pediatric patients presenting with skull fractures from 2000 to 2005 [6]. 772 patients were treated non-operatively. 58 patients underwent fracture repair and 67 patients underwent surgery for treatment of traumatic brain injury. In the non-operative group, falls were the most common mechanism of injury whereas motor vehicle crash and struck in the head by an object were more common mechanisms in the operative patients. The non-operative group was more likely to have parietal fractures whereas the operative groups were more likely to have frontal bone fractures. The traumatic brain injured patients were more likely to have multiple fractures as well as lower Glascow Coma Scale scores. The authors concluded that most children with skull fractures could be managed conservatively. In an editorial accompanying this article it was even suggested that rapid MRI techniques could be substituted for CT scans in head injured children as this would cut down on radiation and the increased risk of missing skull fractures with rapid MRI was unlikely to be important [7].
So back to our 7 month-old baby. He looks good and has reliable parents. You watch him a little longer in the ED and he continues to feed well and to act normally. A repeat neurological exam after a few hours in the ED remains normal. You send him home with close parental observation and return precautions and follow-up with his pediatrician.
REFERENCES
- National Hospital Ambulatory Medical Care Survey (http://www.cdc.gov/nchs/ahcd.htm)-United States, 2001-2010 (Emergency Department Visits).
- Arrey EN, Kerr ML, Fletcher S, et al. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr. 2015;16:703-708.
- Blackwood BP, Bean JF, Sadecki-Lund C. et al. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. J Pediatric Surg. (2015), http://dx.doi.org/10.1016/jpedsurg.2015.08.064.
- Mannix R, Monuteaux MC, Schutzman SA, et al. Isolated skull fractures: trends in management in US pediatric emergency departments. Ann Emerg Med. 2013;62(4):327-331.
- Powell EC, Atabaki SM, Wootten-Gorges S, et al. Isolated linear skull fractures in children with blunt head trauma. Pediatr. 2015;135(4):e851.
- Bonfield CM, Naran S, Adetayo OA, et al. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr. 2014;14:205-211.
- Duhaime Ann-Christine. Do skull fractures matter? J Neurosurg Pediatr. 2014;14:203-204.