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Linear nondisplaced skull fractures in children: who should be observed or admitted?
Eliel N Arrey1, Marcia L Kerr1, Stephen Fletcher1
1Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas.
Insights
Many children with linear nondisplaced skull fractures (NDSFs) do not require hospitalization. Observation may be needed for those with altered mental status, other injuries, or suspected nonaccidental trauma.
Area of Science:
- Pediatric Emergency Medicine
- Pediatric Traumatology
- Pediatric Neurosurgery
Background:
- Linear nondisplaced skull fractures (NDSFs) are common pediatric injuries.
- Management protocols for pediatric NDSFs vary, impacting resource utilization and patient outcomes.
Purpose of the Study:
- To review clinical management and outcomes for children with isolated NDSFs.
- To identify factors influencing hospitalization decisions and associated costs for pediatric NDSFs.
Main Methods:
- Retrospective review of clinical records and imaging for 326 children (0-16 years) with isolated NDSFs.
- Exclusion of fractures that were open, comminuted, or associated with intracranial hemorrhage, multiple fractures, or pneumocephalus.
Main Results:
- Most patients (56%) were observed for <23 hours; 27% were admitted. Hospitalization was often due to Child Protective Services involvement (24 patients) or other injuries (11 patients).
- No patients exhibited neurological deficits or required neurosurgical intervention. Only 16% had outpatient follow-up, with all remaining neurologically intact.
- Altered mental status or loss of consciousness was reported in 13% of patients.
Conclusions:
- Hospitalization is often unnecessary for pediatric patients with isolated NDSFs.
- Observation is recommended for children with NDSFs who present with altered mental status, concurrent injuries, or suspected nonaccidental trauma.
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.
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