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Pediatric Skull Fractures
Introduction
Head injury is common in the pediatric population and is a major cause of morbidity and mortality. The annual incidence is estimated at 250 per 100,000, accounting for approximately 600,000 pediatric emergency department visits each year.[1][2] Pediatric fractures differ from those in adults because of the capacity of children's bones to remodel, although the craniofacial skeleton and brain remain in active development.[3] Infants have a larger head-to-body surface area ratio, decreasing from 18% in infancy to 9% in adulthood. The pediatric skull is thinner and more pliable, offering less protection to the brain and predisposing children to head injuries.[4][5][6][7] About 10% to 30% of pediatric head injuries result in skull fractures, the presence of which increases the risk of intracranial injury.[8][9][10]
Etiology
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Etiology
The causes of pediatric head injuries are broadly categorized as accidental or nonaccidental. Pediatric head trauma and abusive head trauma (AHT) have been extensively studied. However, features of skull fractures predictive of accidental trauma remain poorly defined.[11] Nonaccidental injuries must be considered in all pediatric trauma evaluations, particularly in nonverbal infants, as they account for 30% to 50% of head or neck trauma cases.[12][13][14] Reported mechanisms of pediatric skull fractures include falls, being struck on the head by an object, assault, and motor vehicle collisions.[15][16][17][18][19][20].
Epidemiology
Head injuries are a frequent presentation in the pediatric emergency department and the leading cause of fatal trauma in children. About 80% to 90% are mild, with only a small proportion posing life-threatening risk or requiring neurosurgical intervention, and most children are discharged within 24 hours.[21][22][23] The incidence is estimated at 250 per 100,000 children annually, contributing to over 7,000 deaths, 60,000 hospital admissions, and 600,000 emergency department visits each year in the U.S. Incidence is higher in boys and children younger than 2 years.[24]
Pathophysiology
The skull is divided into the calvarium and the skull base. The calvarium consists of the frontal, parietal, occipital, and temporal bones, while the skull base includes the sphenoid, palatine, and maxillary bones, along with portions of the temporal and occipital bones.
Several fracture types are recognized in children. Simple linear fractures are nondepressed breaks in the skull. Compound fractures, typically depressed by more than 1 cm, are associated with a higher risk of cortical laceration and intracranial lesions.[25]
Pingpong fractures, unique to pediatric patients, appear as indentations of the cranial bones without cortical disruption.[26] Open fractures involve disruption of the cranial vault and carry a high risk of infection. Growing skull fractures, or craniocerebral erosions, usually occur in children younger than 3 years. These injuries involve a skull fracture with disruption of the dura or arachnoid, allowing brain tissue to herniate through the defect and progressively enlarge the fracture gap.[27][28]
Orbital roof fractures, more common in children than in adults, pose a risk of injury to adjacent structures and may result in entrapment of the orbital nerve or soft tissues. Skull base fractures are frequently associated with dural tears and cerebrospinal fluid (CSF) leakage, particularly in the anterior region where the dura is closely attached to the bone. Clinical signs include retroauricular or periorbital bruising, hemotympanum, and CSF otorrhea or rhinorrhea.[29][30]
History and Physical
A detailed history is essential in the evaluation of a child with a head injury. Particular attention should be given to whether the reported mechanism of injury is consistent with the child’s developmental stage and the clinical findings.[31] The American College of Surgeons emphasizes the importance of a standardized protocol for early assessment and stabilization in cases of suspected trauma, including AHT. This framework is outlined in the Advanced Trauma Life Support (ATLS) program.[32] A comprehensive head-to-toe examination should follow, with careful attention to bruising or other injuries, especially when trauma is suspected or nonaccidental injury is a concern.[33]
Examination of the head requires palpation for soft tissue swelling, hematoma, step-off deformities, palpable fractures, or crepitus. Signs of basilar skull fracture should also be sought, including hemotympanum, periorbital ecchymoses (raccoon eyes), retroauricular or mastoid ecchymoses (Battle sign), CSF rhinorrhea or otorrhea, and evidence of cranial nerve deficits, which may include facial paralysis, anosmia, vertigo, nystagmus, tinnitus, hearing loss, papilledema, or visual field defects (see Image. Battle Sign). The ring sign can help confirm the presence of CSF in blood-tinged otorrhea or rhinorrhea. CSF produces a clear halo around the central blood spot when placed on filter paper.[34]
Evaluation
Clinical examination alone cannot reliably exclude significant injury. Thus, imaging plays a central role in the evaluation of pediatric head trauma, providing rapid and accurate identification of skull fractures and intracranial hemorrhage (see Image. Pediatric Skull Fractures, 3-Dimensional Reconstruction).
Noncontrast-enhanced head computed tomography (CT) is the 1st-line modality in the acute setting for detecting skull fractures and intracranial hemorrhage, including subdural, subarachnoid, and epidural bleeds.[35] Clinical decision tools, such as the Pediatric Emergency Care Applied Research Network (PECARN) Head CT Rules, the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), and the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), help reduce unnecessary CT use in children with minor head trauma.[36][37][38]
Skull radiography can identify fractures but is no longer recommended, as head CT offers greater sensitivity for diagnosing both skull fractures and traumatic brain injury.[39][40] When performed by emergency physicians, point-of-care ultrasound (POCUS) has a sensitivity of 77% to 100% and a specificity of 85% to 100% for detecting skull fractures, although its role in decision-making has not been validated.[41][42] Rapid magnetic resonance imaging (MRI) provides radiation-free assessment of skull fractures and traumatic brain injury, but its limited availability, reduced sensitivity for bone fractures, and higher cost restrict its widespread use.[43]
Conventional brain MRI is useful in evaluating suspected AHT, as it can determine the age of hemorrhage, differentiate acute from chronic subdural collections, and detect brain edema, parenchymal ischemia, and ventricular compression. Skeletal surveys remain the standard in children younger than 2 years with suspected abuse, following American College of Radiology guidelines. Typical skeletal surveys include plain radiographs of the skull, spine, ribs, and long bones, with repeat studies after 2 to 3 weeks, improving detection of occult fractures.[44][45][46][47]
Treatment / Management
Initial Stabilization and Resuscitation
The American College of Surgeons recommends a standardized protocol for the early assessment and stabilization of patients with suspected trauma, including AHT. The initial evaluation begins with a primary survey guided by the ABCDE approach, as follows:
- Airway with cervical spine protection
- Breathing assessment
- Circulation evaluation with hemorrhage control
- Disability assessment, including neurological status using the Glasgow Coma Scale (GCS)
- Exposure, with complete undressing to visualize injuries while maintaining temperature control
An age-appropriate pediatric GCS may be applied in preverbal children.[48] Neurological assessment emphasizes 3 components of responsiveness, including eye opening (1-4), verbal response (1-5), and motor response (1-6), which, together, determine the GCS score.[49]
Nonsurgical Management
Simple, linear, isolated skull fractures without associated brain injury generally require no intervention. Patients with these fractures may be safely discharged directly from the emergency department without the need for hospital admission.[50][51]
Indications for Neurosurgical Intervention
Neurosurgical intervention is reserved for specific high-risk skull fractures and their associated complications, as most pediatric head injuries can be managed conservatively. Surgery is indicated to prevent life-threatening consequences, protect neural structures, and reduce long-term morbidity. The following conditions comprise the indications for surgical treatment of pediatric skull fractures:
- Frontal bone fractures in older children with aerated frontal sinuses
- Depressed skull fracture deeper than 5 mm
- Dural injury requiring repair
- Presence of an underlying hematoma
- Grossly contaminated wounds
- Open fractures
- Basal skull fractures with CSF leak. Untreated CSF leakage may result in meningitis, hydrocephalus, subdural fluid collections, and neurocognitive complications.[52]
- Growing skull fracture requiring dural repair with or without cranioplasty [53][54]
- Orbital roof fractures
- Sphenoid wing fractures
Operative management is tailored to the fracture pattern and extent of injury, with options including hematoma evacuation, dural closure, sinus repair, and reconstructive cranioplasty. Early neurosurgical involvement is essential to prevent infection, long-term neurocognitive impairment, and structural deformity.
Differential Diagnosis
Pediatric skull fractures share overlapping features with several benign or pathologic conditions that also cause scalp or cranial contour changes. These clinical entities include the following:
- Subgaleal hematoma
- Infections, such as subdural effusion or empyema
- Birth injuries
- Bony dyscrasias
- Scalp laceration
- Scalp hematoma
Diagnostic accuracy relies on history, physical examination, and imaging, which clarify whether findings arise from trauma, infection, or congenital bone disorders. CT and MRI provide key details to confirm or exclude a fracture.
Prognosis
The prognosis is generally favorable when the following discharge criteria are met:
- Absence of significant extracranial injuries
- No clinical signs of intracranial pressure elevation, such as persistent vomiting, severe headache, or focal neurological deficits
- Normal mental status and neurological examination
- No suspicion of abuse, neglect, or nonaccidental trauma (NAT)
- Presence of reliable caregivers able to return promptly if symptoms progress [55]
Outcomes are poor when skull fractures are accompanied by intracranial pathology, raised ICP, or missed signs of NAT. Favorable prognosis depends on early identification, appropriate neurosurgical referral when indicated, and safe discharge planning with reliable follow-up.
Complications
The main complications associated with pediatric skull fractures include the following:
- Seizures, including status epilepticus
- Persistent headaches
- Learning difficulties
- Behavioral and cognitive impairment
- Venous sinus thrombosis
- Intracerebral hemorrhage
- Meningitis or encephalitis, particularly with open fractures
- Growing skull fracture
- CSF leak
- Ocular injury or visual impairment
- Cosmetic deformity
Most complications result from the initial trauma rather than from neurosurgical intervention performed during management.
Consultations
Collaboration with trauma surgery, pediatric neurosurgery, child abuse pediatrics, plastic surgery, and ophthalmology has demonstrated clear benefit.[56][57][58] Such interprofessional coordination reduces the risk of missed injuries, facilitates timely interventions, and optimizes both functional and cosmetic outcomes in children with skull fractures.
Deterrence and Patient Education
Educating parents and caregivers regarding safety is essential in preventing pediatric injuries and skull fractures. Helmets should always be worn when bicycles, scooters, or skateboards are used, or when children participate in sports with a risk of head injury. Car or booster seats appropriate for age and size should be used, and transition to seat belts should occur only when the recommended height and weight requirements are met. Head-first sliding on sleds or playground slides should be avoided. Close supervision should be provided at water parks and pools, and all posted safety rules should be followed.
Pearls and Other Issues
Most pediatric skull fractures can be managed nonoperatively. However, fracture patterns of the cranial vault and skull base differ from those in adults because of developmental anatomy, thus requiring close monitoring for complications unique to children. Surgical management also differs from adult techniques, particularly in cases of growing skull fractures, orbital involvement, and bone flap resorption.
Most complications from these injuries arise from the initial trauma rather than neurosurgical procedures. Skull fractures may lead to CSF leak, ocular complications, and cosmetic deformity, whereas neurosurgical intervention rarely alters the course of posttraumatic seizures, headaches, learning disabilities, or behavioral and cognitive difficulties. Concerns regarding patient safety or suspected NAT should be systematically evaluated and managed with a thorough, objective, and interprofessional approach.
Enhancing Healthcare Team Outcomes
Effective management of pediatric skull fractures requires an interprofessional approach, incorporating expertise from trauma surgery, pediatric neurosurgery, general pediatrics, child abuse specialists, and social work to ensure comprehensive care. Suspected cases of NAT must be reported to Child Protective Services in accordance with mandatory reporting guidelines. Outcomes range from mild cognitive impairment to severe disability or death. The prognosis is determined by several factors, including associated systemic injuries, the presence of neurological deficits at presentation, a low GCS score, and the need for mechanical ventilation.[59][60]
Media
(Click Image to Enlarge)
Pediatric Skull Fractures, 3-Dimensional Reconstruction. This 3-dimensional computed tomography reconstruction of a pediatric skull exhibits a prominent fracture crossing the superior sagittal sinus at the midline, accompanied by additional linear fractures extending laterally and involving cranial sutures such as the sagittal and coronal sutures. The complex fracture pattern indicates extensive calvarial involvement, raising concern for underlying vascular and dural sinus injury.
Contributed by S Munakomi, MD
(Click Image to Enlarge)
Battle sign Image courtesy S Bhimji MD
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