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Re-Examining the Brain Injury Guidelines in Pediatric Traumatic Brain Injury: Can Simple Isolated Non-Displaced Skull
Jose Castillo1, Jonathan T Mo2, Dharminder S Ojla2
1Department of Neurological Surgery, University of California, Davis, Sacramento, California, USA.
Journal of Neurotrauma
|February 27, 2025
Summary
Hospital admission for children with simple skull fractures is often unnecessary. These patients rarely develop complications, suggesting a reclassification to a lower injury category could reduce hospitalizations and transfers while ensuring safety.
Area of Science:
- Pediatric Traumatology
- Neurotrauma Research
- Clinical Guidelines Development
Background:
- Mild traumatic brain injury (TBI) in children frequently leads to over-utilization of imaging and hospital admissions.
- Current Brain Injury Guidelines (BIG) classify non-displaced skull fractures as BIG-2 injuries, necessitating hospitalization.
- Clinical observations suggest isolated, non-displaced skull fractures rarely cause significant TBI complications.
Purpose of the Study:
- To evaluate the necessity of hospital admission for pediatric patients with simple, isolated, non-displaced skull fractures.
- To determine the incidence of clinically important TBI (ci-TBI) in this patient group.
- To assess patient outcomes and inform potential revisions to the BIG classification.
Main Methods:
- Retrospective study of pediatric TBI admissions (2018-2023) requiring neurosurgery consultation.
- Inclusion criteria: age ≤17, isolated non-displaced skull fracture, Glasgow Coma Scale (GCS) 14-15, and no intracranial injury.
- Exclusion criteria: skull base fractures, sagittal sinus involvement, or other intracranial injuries. Analysis of imaging, interventions, and 6-month outcomes (GOS-E).
Main Results:
- Analyzed 804 subjects; 247 had simple, isolated, non-displaced fractures without intracranial injury (BIG-2).
- Of these, 198 were transferred from other hospitals. No significant imaging progression, neurosurgical intervention, or ci-TBI occurred (0/247).
- Favorable outcomes (GOS-E 5-7) were observed in 98.5% of patients with available 6-month follow-up.
Conclusions:
- Children with simple, isolated, non-displaced skull fractures rarely develop ci-TBI.
- Hospital admission and observation for these injuries may be unnecessary.
- Reclassifying these fractures to BIG-1 could decrease admissions and transfers without compromising patient safety, warranting a revision of the BIG classification.
