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Presentation, Evaluation, and Outcomes of Infants Under 3 Months With Skull Fractures
Katherine Mandeville1, John Naheedy2, Zaineb Boulil3
1Department of Pediatrics, UCSD School of Medicine, Rady Children's Hospital, Division of Emergency Medicine, San Diego, California.
Insights
Infants with skull fractures, even from minor injuries, frequently have intracranial hemorrhage (ICH). Over a quarter of these cases require evaluation for nonaccidental trauma (NAT), highlighting the need for careful assessment in this age group.
Area of Science:
- Pediatric Traumatology
- Neurotrauma
- Child Abuse Pediatrics
Background:
- Head injuries in infants are common and difficult to diagnose.
- Subtle injury mechanisms can lead to severe outcomes.
- Risk of nonaccidental trauma (NAT) complicates assessment.
Purpose of the Study:
- Evaluate clinical presentations, assessments, and outcomes in infants with skull fractures.
- Determine the incidence of intracranial hemorrhage (ICH) in these infants.
- Analyze factors associated with ICH and outcomes.
Main Methods:
- Retrospective chart review of 291 infants with skull fractures.
- Data collected via computed tomography (CT) imaging and ICD codes.
- Analysis of clinical findings, injury mechanisms, and outcomes.
Main Results:
- Most infants (80%) had reported falls; 83% presented with scalp hematomas.
- Intracranial hemorrhage (ICH) occurred in 55% of cases.
- Child welfare assessments were common (64%), especially with ICH (p < 0.001).
Conclusions:
- Infants under 3 months with skull fractures often have ICH despite minor injury mechanisms.
- Subtle symptoms are common, necessitating clinical vigilance.
- Nearly a quarter of cases warrant nonaccidental trauma (NAT) evaluation.
Background:
Head injuries in infants are common but challenging to assess due to minor mechanisms potentially causing significant injury, nonspecific symptoms, and the risk of nonaccidental trauma (NAT).
Study Objectives:
This study evaluates clinical presentations, assessments, and outcomes in infants with skull fractures, with and without intracranial hemorrhage (ICH).
Methods:
A retrospective chart review was conducted at a tertiary care children's hospital, identifying 291 infants (mean age: 6 weeks) with skull fractures via computed tomography imaging and ICD9/ICD10 codes.
Results:
Most infants (80%, n = 232) had reported falls, and 83% (n = 240) presented with scalp hematomas. Glasgow Coma Scores were 14 to 15 in 81% (n = 234), while 1.5% (n = 5) scored below 8. ICH was present in 55% (n = 161), with subdural hemorrhage being the most common (53%, n = 86). Vomiting occurred in 8% (n = 23), with loss of consciousness rare (2%, n = 7). Provider-documented normal behavior (84%, n = 244) and parent-reported normal behavior (53%, n = 155) showed relative risks of 1.32 and 1.21 for ICH, respectively. Fracture type (75% nondisplaced/nondepressed, 21% displaced/depressed) did not predict ICH (p = 0.20). Critical care admission was required for 61% (n = 178), and 4% (n = 12) underwent surgery. Child welfare assessments were conducted in 64% (n = 186), more frequently in ICH cases (65%, n = 120 vs. 35%, n = 66; p < 0.001). Skeletal surveys (21%, n = 62) were abnormal in 24% (n = 15).
Conclusion:
Infants under 3 months with skull fractures often present with minor injury mechanisms and subtle symptoms, yet over half have ICH, and nearly a quarter require evaluations for NAT. Clinicians should exercise caution when assessing head injuries in this age group.
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