Skull film radiography in the management of head trauma

The contribution of plain skull radiography to the management of head trauma has been a subject of debate for more than 20 years. In an effort to reduce overutilization, criteria have been developed to identify those patients likely to have positive diagnostic results; these were called "high-yield criteria." Such high-yield criteria have been shown to reduce significantly the ordering of skull radiographs without any apparent adverse effect on patients. Several issues must be addressed before high-yield criteria or referral criteria can be promulgated on a nationwide basis. First, it must be determined whether the criteria applicable to a pediatric population differ from the criteria applicable to an adult population. Second, studies must be conducted to determine the outcome of patients who are not radiographed when high-yield criteria are used. A more fundamental issue, perhaps, is whether the identification of a fracture has any impact on patient management. It may, in fact, be more relevant (as Masters suggests) to develop a set of criteria to identify those patients in whom significant sequelae would be expected. Physician acceptance of referral criteria for ordering skull radiographs may depend ultimately on the direction taken on the medicolegal issue in this country, and on patient and physician attitudes regarding the necessity of knowing whether the patient has sustained a simple skull fracture.