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Three Part Question

In [children with minor head injury] does [absence of skull fracture] predict [absence of ICI]?

Clinical Scenario

Different Emergency Departments have different protocols/preferences in the way children with mild or minor head injury are investigated. Some prefer observation plus or minus plain skull X-ray, others use head scan as the first choice modality. The department you are currently working in uses plain radiology. You are concerned that in children with mild head injury with no abnormal neurology and no fracture seen on plain skull films there is a tendency to be falsely reassured that intra-cranial injury (ICI) is unlikely.

Search Strategy

Medline 1985-08/2001 using the OVID interface.
{(exp brain injuries/ or exp craniocerebral trauma/ or exp head injuries, closed/ or head trauma.mp or head injur$.mp or exp skull fractures/ or skull fracture$.mp) AND (exp child/ or exp adolescence/ or exp child, abandoned/ or exp child, exceptional/ or exp child, hospitalized/ or exp child, institutionalized/ or exp child of impaired parents/ or exp child, preschool/ or exp child, unwanted/ or exp disabled children/ or exp homeless youth/ or exp infant/ or exp only child/ OR child$.mp or exp pediatrics/ or pediatric$.mp or paediatric$.mp) AND (exp tomography scanners, x-ray computed/ or exp tomography, x-ray computed/ or tomography.mp or CT scan$.mp) AND (exp prospective studies/ or prospective.mp or prospectively.mp)} LIMIT to (human and English language and yr=1985-2001)

Search Outcome

194 papers were found, of which 187 were irrelevant or of insufficient quality to include.The remaining 7 papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chan KH et al, 1990 Hong Kong	1178 adolescents (11-15 years)	Prospective	Fracture on plain skull X-ray with ICI	13 of 26 with skull fracture developed ICI. 10 of these had admission GCS of 15	Not restricted to mild head trauma. CT's done selectively.
			ICI without fracture	Of those CTed 4 developed diffuse brain swelling
Levi L et al, Israel 1991	Sub group of 384 (GSC 13-15) from 653 children <15 years old analysed from paper.	Prospective	Skull fracture and ICI	Of 97 children 22% had ICI
			No skull fracture and ICI	Of 287 children 15% had ICI
Dietrich AM et al, 1993 USA	Sub-group of 233 children with minor head injury and GCS 15, all were head scanned. Mean age 7.1 years, 62% male. (January 1st 1990 to December 31st 1990)	Prospective. Cohort.	CT results.	11% had isolated skull fracture. 5% had intra-cranial injury +/- fractured skull, none of whom had abnormal neurology.	Results shown are secondary outcomes of the study. Not clear if truly prospective. The incidence of skull fracture with ICI was not given.
			Plain skull X-rays.	64% of isolated skull fractures were seen on plain skull radiograph. No deaths.
Lloyd DA et al, 1997 UK	883 head injured children	?Prospective data over 2 years	Skull fracture on X-ray and CT	66% of 162 with skull fracture were CTed of which 13% had ICI	Not restricted to mild trauma. Only 18% had head CT. Not clearly prospective Up to 23% of skull fractures not seen by ED staff
			No skull fracture and CT	Only 6% of 708 CTed of which 9% had ICI. Remainder went to CT (4 out of 5 who were CTed had ICI with no fracture) or observed only.
Quayle KS et al, 1997 USA	Data collected in 322 'non-trivial' head injuries.	Prospective. Cohort.	Skull radiograph and head CT. Surgical follow up.	15.5% had skull fracture +/- ICI. 8.4% had ICI. 59% (16) of those with intra-cranial injury had GCS 15 and no focal neurology - 1 of whom required neurosurgery. 6 of these asymptomatic children were < 1 year (5/6 had scalp haematoma).	410 children originally identified as 'non-trivial'. Selective and incomplete data collection on subgroup. Not restricted to mild trauma.
Greenes DS, Schutzman SA. 1999 USA	608 infants < 2 years. (11.2 +/- 6.8 months, 57% male)	Prospective (selected CT scan).	Imaging	15.9% of those scanned had intra-cranial injury - 77% of whom had skull fracture. 27.7% of those imaged had skull fracture diagnosed - 26.1% of whom had intra-cranial injury. 2.1% of those who were CT scanned had evacuation of haematoma.	Only 31% had head CT, with a further 20% having skull x-ray only. GCS not formally used.
			Disposition	No deaths
Wang MY et al, 2000 USA	157 children with 'field'/paramedic GCS (or infant CS) of 13-14 = 15 years transported by ambulance to a trauma center over twelve month period.	Prospective, multicenter.	Head CT results	27.4% had abnormal CT. 19.1% with intra-cranial haemorrhage - 53% of whom had no fracture. 18.5% had skull fractures - 48% of whom had intra-cranial haematoma 3.2% had evacuation of intra-cranial haematoma.	Data not available for 52 additional patients who fitted inclusion criteria but were not transported to the trauma center. No plain radiology.
			Disposition	No deaths

Comment(s)

Seven prospective papers were found. No consistent evidence exists to show that the presence or absence of skull fracture reliably predicts ICI. There is a suggestion that older children with skull fracture may have higher risk for ICI. Computerised tomography was used to show isolated ICI (i.e. no fracture seen), in 4-15% of children with mild head injury (GCS=13). The significance of ICI in this group remains unclear, 1-3% have neurosurgery implying that missed ICI from mild head injury can occasionally have severe consequences.

Clinical Bottom Line

The absence of skull fracture does not predict absence of intra-cranial injury as seen on computerised tomography. Computerised tomography is therefore the imaging modality of choice if intra-cranial injury is to be excluded in children with mild head injury.

References

1. Chan KH, Mann KS, Yue CP et al. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J of Neurosurg 1990;72(2):189-194.
2. Levi L, Guilburd JN, Linn S et al. The association between skull fracture, intracranial pathology and outcome in pediatric head injury. Brit J Neurosurgery 1991;5(6):617-625.
3. Dietrich AM, Bowman MJ, Ginn-Pease ME, et al. Pediatric head injuries:can clinical factors reliably predict an abnormality on computed tomography? Annals of Emergency Medicine. 1993;22(10):1535-40.
4. Lloyd DA, Carty H, Patterson M et al. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet. 1997;349(9055):821-4.
5. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics. 1997;99(5):E11.
6. Greenes DS, Schutzman SA. Clinical indicators of intracranial injury in head-injured infants. Pediatrics. 1999;104(4 Pt-1):861-867.
7. Wang MY, Griffith P, Sterling J, et al. A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow coma scale of 13-14). Neurosurgery. 2000; 46(5):1093-99.