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Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma
Michael G Tunik1, Elizabeth C Powell2, Prashant Mahajan3
1Departments of Emergency Medicine and Pediatrics, NYU School of Medicine, New York, NY.
Insights
Approximately 1% of children with blunt head trauma exhibit signs of basilar skull fracture. Computed tomography (CT) is crucial for risk assessment, as isolated fractures carry a low risk of adverse outcomes.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Radiology
Background:
- Basilar skull fractures in children following blunt head trauma require careful evaluation in the emergency department (ED).
- Distinguishing between clinical signs and computed tomography (CT) findings is essential for accurate diagnosis and risk stratification.
Purpose of the Study:
- To describe the clinical presentations and outcomes of pediatric patients diagnosed with basilar skull fractures after blunt head trauma.
- To evaluate the diagnostic accuracy of physical examination signs versus CT findings for basilar skull fractures.
- To assess the risk of acute adverse outcomes associated with different types of basilar skull fractures in children.
Main Methods:
- Secondary analysis of an observational cohort of children with blunt head trauma.
- Defined basilar skull fracture based on physical examination and/or CT findings.
- Classified fractures as isolated or with other intracranial injuries.
- Defined acute adverse outcomes including death, neurosurgery, prolonged intubation, and hospitalization.
Main Results:
- Approximately 1.3% of children with blunt head trauma presented with signs or CT evidence of basilar skull fracture.
- CT confirmed basilar skull fracture in a subset of patients with physical examination findings.
- No acute adverse outcomes were observed in children with isolated basilar skull fractures, including those diagnosed solely by CT.
Conclusions:
- Basilar skull fractures occur in about 1% of pediatric blunt head trauma cases.
- CT imaging is necessary to accurately assess the risk of adverse outcomes.
- Children with isolated basilar skull fractures demonstrate a low risk for adverse outcomes and may be candidates for ED discharge if neurologically stable.
Study Objective:
We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma.
Methods:
This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT).
Results:
Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT.
Conclusion:
Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.
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