[Selective indications of skull radiography after head injury in children]

Skull X-rays are systematically performed on children after head injuries in most hospitals. However, the discovery of a skull fracture as an isolated finding rarely warrants intervention. In february 1994, we stopped performing systematical skull X-rays in children after head injuries. We report the results of this experience.

Since February 1994, only children with possible skull penetration, depressed fracture, or presenting signs of basilar fracture had X-ray examination. Facial injuries were excluded in this study. In case of focal neurologic signs, neurosurgical consultation, or emergency CT examination, or both were performed. In case of change of consciousness at the time of injury or subsequently, the child was hospitalised for clinical observation for 48 hours, but no X-ray examination was performed. Children without any neurological signs or change of consciousness were discharged to their homes after they were given a head-injury instruction sheet, and if a second person could observe them for signs indicating that they belong to a higher risk group, but no X-ray examination was performed.

An average of 241 children per month were presented at the Children Emergency Unit after head trauma. An average of twenty-one X-ray examinations per month were performed instead of 194/month before february 1994. This represented a decrease of 2000 X-ray examinations per year. There was no undiagnosed neurological complication, and the number of children staying in the hospital for clinical supervision did not increase.

Skull radiographies only show fractures and do not afford visibility of either brain or blood to demonstrate an intracranial injury. The presence of a skull fracture without neurological abnormalities is of little significance. Harwood-Nash reported that 60 per cent of the children with extradural hematoma, 85 per cent of the children with subdural hematoma and 35 per cent of the children with brain damage did not have any associated skull fracture. Clinical examination is essential, and it would be a mistake to be reassured about the severity of a head trauma because skull X-rays are normal.

Routine skull X-rays after head trauma are not justified either for financial or radioprotection reasons. In this study, more than half of the children were less than five years old and ran a higher risk of irradiation.