Natural History and Clinical Implications of Nondepressed Skull Fracture in Young Children

Head injury is the most common cause of neurologic disability and mortality in children, and it is a frequent indication for evaluation of pediatric patients in the emergency department. Fortunately, most do not require neurosurgical intervention. There is a current dilemma regarding disposition in pediatric patients who have relatively minor head trauma, such as concussion or minimally displaced skull fracture. This study evaluated children 5 years or younger who sustained an isolated skull fracture (SF) in the absence of any other trauma and hypothesized that nondepressed skull fractures (NDSFs) in the pediatric population were not associated with adverse neurologic outcomes. In this study, 223 children had SFs after isolated head injury. These patients were divided into depressed skull fracture (DSF) and NDSF groups. One hundred sixty-three children had NDSFs, which were further divided into Glasgow Coma Scale (GCS) score of 15 and GCS score of ≤ 15. A total of 128 children (78%) in the NDSF group presented with a GCS score of 15. None of the patients with NDSFs and a GCS score of 15 required neurosurgical intervention or developed any neurologic deficit. Sixty children had DSFs, of these, 35 had a GCS score of 15 on presentation. None of the children with DSFs and a GCS score of 15 on presentation had a persistent neurologic deficit, and only two had temporary neurologic deficits that resolved before hospital discharge. The DSF group was risk stratified based on magnitude of depression (0 to 0.5, 0.5 to 1.0, and > 1.0 cm) and the magnitude of depression was associated with the likelihood of severe neurologic deficit. None of the 164 patients with SF (both DSF and NDSF) and a GCS score of 15 developed a persistent neurologic deficit. However, neurologic deficit was common in patients with SF and a GCS score of < 15 at presentation. This study found that children 5 years and younger with SFs and a GCS score of 15 did not develop neurologic deficits. However, children with SFs and a GCS score of < 15 seem to be at major risk for serious neurologic dysfunction and death. Because every child in this study with a GCS score of 15 and a NDSF was safely discharged without any neurologic deficit or need for neurosurgical intervention, the researchers recommend that these children may be discharged directly from the emergency department.