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Three Part Question

What is the [accuracy of the physical examination] to [identify skull fractures] in [pediatric patients presenting to the ED]?

Clinical Scenario

A 5-year-old female presents to the emergency department after a fall from playground equipment. Parents are concerned about significant head injury. You perform history and physical exam and would like to use a pediatric head injury algorithm to help guide your need for advanced imaging and you hope to avoid unneeded imaging. You wonder how accurate your exam is for pediatric skull fracture.

Search Strategy

Medline 1966-01/24 using PubMed, Cochrane Library (2024), and Embase
[Skull fractures diagnosis AND physical examination]

Search Outcome

44 studies were identified; 3 studies addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Akie TE, et al March 2023 USA	1,018 pediatric patients with head injury; 81 with skull fractures	Retrospective observation study	Sensitivity of provider physical examination to detect skull fractures	18.5% (95% confidence interval 10.5% to 28.7%)	Retrospective secondary analysis of a previously collected database of pediatric patients presenting with a blunt head injury. All participants had to have a CT head obtained at the index visit (verification bias). CT images were not independently reviewed or determined by consensus, which may have resulted in the incorrect assignment of injuries. Numbers of depressed and basilar skull fractures were low.
			Specificity of provider physical examination to detect skull fractures	96.6% (95% CI 95.3% to 97.1%)
Tunik MG, et al October 2016 USA	43,399 pediatric patients with blunt head trauma occurring within 24 hours before ED evaluation	Observational cohort study (secondary analysis)	Physical examination findings suggestive of basilar skull fractures	CT showed basilar skull fracture in 28.7% of patients with examination findings	CT scans were not performed on all children; some patients with basilar skull fractures may therefore have been missed. Some of the equivocal CT interpretations were interpreted as normal results. There was no set definition of physical examination signs of basilar skull fractures. Long-term adverse events were not identified in follow-up.
			Adverse outcomes in patients with isolated basilar skull fracture and normal neurologic examinations	0% (95% CI 0% to 1.4%)
Gravel J, et al November 2015 Canada	A total of 1667 children less than 2 years old who had head trauma (93 with skull fracture)	Prospective cohort study in 3 tertiary care emergency departments	Sensitivity of clinical decision rule to detect skull fracture	89% (95% CI 76%–95%)	Not all of the patients had a radiologic evaluation; study took place in tertiary care settings (selection bias); interrater reliability was not measured[ small number of children with skull fractures; the clinical decision rule was validated in the same sites as those used in the derivation phase; and the decision rule was not used by the treating physicians in the validation phase.
			Specificity of clinical decision rule to detect skull fracture	87% (95% CI 84%–89%)

Comment(s)

The accuracy of a physical exam in detecting skull fractures in older children can vary, and it is influenced by factors such as the experience and expertise of the healthcare provider, the type of fracture, and the presence of other symptoms. In general, studies suggest that physical exams alone may not be sufficient to diagnose all skull fractures, especially if the fracture is not accompanied by noticeable external signs. In children less than 2 years old who had acute head trauma, a clinical decision rule (parietal or occipital swelling or hematoma and age less than 2 months) identified about 90% of skull fractures. However, this rule has not been externally validated.

Clinical Bottom Line

Clinician physical exam is poorly sensitive for skull fracture in pediatric patients presenting to the ED with blunt head trauma.

References

1. Akie TE, Gupta M, Rodriguez RM, Hendey GW, Wilson JL, Quinones AK, Mower WR. Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomogr Ann Emerg Med 2023 Mar;81(3):334-342
2. Tunik MG, Powell EC, Mahajan P, Schunk JE, Jacobs E, Miskin M, Zuspan SJ, Wootton-Gorges S, Atabaki SM, Hoyle JD Jr, Holmes JF Jr, Dayan PS, Kuppermann N; Pediatric Emergency Care Applied Research Net Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma. Ann Emerg Med 2016 Oct;68(4):431-440
3. Gravel J, Gouin S, Chalut D, Crevier L, Décarie JC, Elazhary N, Mâsse B. Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma CMAJ 2015 Nov 3;187(16):1202-1208