Validation of a clinical score to predict skull fracture in head-injured infants
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Steven S Bin1, Sara A Schutzman, David S Greenes
1Department of Emergency Medicine, Mary Bridge Children's Hospital, 315 Martin Luther King Jr. Way, Tacoma,WA 98405, USA. Steven.Bin@Multicare.org
Insights
This study validates a clinical score for identifying skull fracture risk in infants with head injuries. A score of 4 or higher accurately detects fractures, while a score of 3 or higher is best for detecting intracranial injury.
Area of Science:
- Pediatric emergency medicine
- Clinical decision support
- Trauma care
Background:
- Head injuries in infants require accurate risk assessment for skull fractures.
- A previously derived clinical score utilizes age, scalp hematoma size, and location.
- This score ranges from 0 to 8 to predict injury risk.
Purpose of the Study:
- To validate a clinical scoring system for identifying infants at risk of skull fracture.
- To assess the score's utility in detecting intracranial injury in pediatric head trauma.
- To determine optimal score thresholds for different injury types.
Main Methods:
- Prospective observational study of children under 2 years with blunt head trauma.
- Inclusion of patients who underwent head imaging for validation.
- Assessment of the clinical score's sensitivity and specificity for skull fracture and intracranial injury.
Main Results:
- In 203 patients, 25% had skull fractures and 14% had intracranial injuries.
- A score of ≥4 identified 90% of skull fractures (sensitivity 0.90, specificity 0.78).
- A score of ≥3 identified 93% of intracranial injuries (sensitivity 0.93, specificity 0.42), including 100% of asymptomatic cases.
Conclusions:
- The clinical scoring system is validated for assessing infant skull fracture risk.
- A score of ≥4 optimizes sensitivity and specificity for skull fractures.
- A score of ≥3 may be preferable for detecting intracranial injury in head-injured infants.
Objectives:
To validate a previously derived clinical score that uses clinical signs to determine which head-injured infants are at risk of skull fracture. The clinical score is calculated on the basis of the patient's age, the scalp hematoma size, and the location of the hematoma, with a total value between 0 and 8.
Methods:
We performed a prospective observational study of children younger than 2 years with blunt head trauma presenting to an urban pediatric emergency department. Among subjects who had head imaging performed (validation set), we assessed the utility of our clinical score to detect skull fracture and intracranial injury.
Results:
In the 203 patients with imaging, 51 (25%) were diagnosed with skull fracture and 29 (14%) with intracranial injury. A clinical score of 4 or greater identified 90% (46/51) of patients with skull fracture with a sensitivity of 0.90 (95% confidence interval [CI], 0.78-0.96) and a specificity of 0.78 (95% CI, 0.70-0.84). A clinical score of 3 or greater identified 93% (27/29) of those with an intracranial injury with a sensitivity of 0.93 (95% CI, 0.76-0.99) and a specificity of 0.42 (95% CI, 0.35-0.50). A score of 3 or greater identified 100% of intracranial injury among asymptomatic patients.
Conclusions:
We have validated our clinical scoring system as an accurate way of determining an infant's risk of skull fracture. Whereas a clinical score of 4 or greater maximizes the trade-off between sensitivity and specificity for identifying skull fracture, a clinical score of 3 or greater may be preferable for detecting intracranial injury.
