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Skull fractures in children: altered conscious level is the main indication for urgent CT scanning
H S Read1, A J Johnstone, W G Scobie
1Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburg, Scotland, UK.
Insights
Children with skull fractures and diminished consciousness require urgent CT scans. Those with normal consciousness may be monitored, especially if the injury resulted from tripping.
Area of Science:
- Pediatric Traumatology
- Neuroradiology
- Emergency Medicine
Background:
- Current guidelines suggest all pediatric skull fractures warrant urgent CT scans.
- This approach may strain resources and lead to unnecessary radiation exposure in children.
Purpose of the Study:
- To evaluate the role of consciousness level in determining the need for urgent CT scans in pediatric skull fractures.
- To assess the mechanism of injury as a secondary factor for intracranial injury risk.
Main Methods:
- Retrospective review of 140 children with skull fractures from falls over 7 years.
- Analysis of consciousness level, injury mechanism, CT findings, and outcomes.
Main Results:
- 13 children had diminished consciousness; 7/9 CT scans revealed significant intracranial injury.
- 127 children with normal consciousness recovered fully; 1/8 CT scans showed minor, untreated subarachnoid hemorrhage.
- Diminished consciousness correlated with falls from height; tripping injuries did not cause diminished consciousness or significant intracranial injury.
Conclusions:
- Urgent CT scanning is indicated for pediatric skull fractures with diminished consciousness.
- Children with skull fractures and normal consciousness can be managed with neuro-observation, particularly if the injury mechanism is low-risk (e.g., tripping).
Abstract:
It has been suggested that all children with skull fractures require urgent CT scanning to exclude intracranial injury. Adhering to such a policy could both tax limited scanning facilities and result in unnecessary exposure to radiation. The aim of this study is to assess the level of consciousness in determining the need for urgent CT scanning, and the possible role of the mechanism of injury as a secondary risk factor. We identified 140 children admitted during a 7-year period with a skull fracture after falling outside the home. Thirteen children had a diminished level of consciousness. Scans were performed in nine, and seven of the scans revealed significant intracranial injuries. By comparison, all 127 children with a normal level of consciousness recovered fully. Scanning was performed in only eight of them; seven scans were normal and one revealed a small subarachnoid heamorrhage which did not require active treatment. In addition, all 13 children with a diminished level of consciousness had sustained their injuries by falling from greater than their own standing height. By comparison, none of the children who had sustained their skull fractures by tripping up had a diminished level of consciousness or a significant intracranial injury. We conclude that all children with a diminished level of consciousness need to undergo an urgent CT scan. Children with skull fractures and a normal conscious level may be managed initially by neuroobservations and the clinician may be further reassured if the child's injury resulted from tripping up.