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Ophthalmology Examinations in Children With Skull Fractures and Underlying Focal Hemorrhage
Karli Breeden1, Cindy W Christian1, Joanne N Wood2
1Division of General Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.
Insights
Retinal examinations may not be necessary for young children with skull fractures and minor head injuries if they appear well. This study found no retinal hemorrhages in this specific pediatric population, suggesting a potential change in clinical practice for abuse evaluations.
Area of Science:
- Pediatric medicine
- Ophthalmology
- Forensic medicine
Background:
- Skull fractures and intracranial hemorrhages in young children can be signs of physical abuse.
- Retinal examinations are crucial for detecting abusive head trauma, but their utility in specific injury patterns is debated.
Purpose of the Study:
- To determine the frequency and diagnostic yield of retinal examinations in children under 2 years old with skull fractures and small intracranial hemorrhages undergoing abuse evaluations.
- To identify factors associated with performing retinal examinations in this cohort.
Main Methods:
- A cross-sectional study using the Child Abuse Pediatric Network (CAPNET) database.
- Included children under 2 years with skull fractures and limited intracranial hemorrhage.
- Analyzed rates of retinal examination, detection of retinal hemorrhages, and associated clinical factors.
Main Results:
- Of 242 children, 43% had retinal examinations; none showed retinal hemorrhages (95% CI: 0-2.8%).
- Children without reported accidental trauma, with higher concern for abuse, or with occipital fractures were more likely to undergo retinal exams.
- Significant variation in retinal examination rates was observed across CAPNET sites.
Conclusions:
- Retinal examinations may be safely forgone in neurologically well-appearing children under 2 with skull fractures and minor intracranial hemorrhages.
- Findings support a more targeted approach to retinal examinations in specific pediatric injury presentations during abuse evaluations.
Objectives:
To assess the frequency and yield of retinal examination in children below 2 years old undergoing abuse evaluations in the setting of skull fracture(s) and small underlying intracranial hemorrhage.
Methods:
This cross-sectional study used CAPNET, a multicenter child physical abuse network, to identify children below 2 years with a skull fracture(s) and intracranial injury limited to an underlying small focal intracranial hemorrhage undergoing subspeciality child abuse evaluations. Our outcomes of interest were (1) the performance of a retinal examination, (2) the identification of retinal hemorrhages, and (3) associations of clinical factors and CAPNET site with the performance of retinal examinations. We hypothesized that retinal hemorrhages would be identified in <5% of patients.
Results:
Of 242 children who met inclusion criteria, the majority (189, 78.1%) presented with a reported history of accidental trauma, and most (211, 87.2%) lacked additional injuries. Only 9 (3.7%) had loss of consciousness and/or seizures/seizure-like activity. The majority (201, 83.1%) had low concern for abuse. Overall, 104 (43.0%) children underwent retinal examinations, of which 0 had retinal hemorrhages (one-sided 95% CI: 0-2.8%). Children without a reported accidental mechanism of injury ( P =0.004), those with intermediate/high concern for abuse ( P <0.001), and children with occipital fractures ( P =0.008) were more likely than their counterparts to undergo retinal examination. The proportion of children undergoing retinal examination varied by CAPNET site ( P <0.001).
Conclusions:
Our findings suggest that it may be reasonable to forgo retinal examinations in children below 2 years of age with skull fracture(s) and intracranial injury limited to an underlying small focal hemorrhage who are overall neurologically well-appearing.
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