Skull fracture as a herald of intracranial abnormality in children with mild head injury: is there a role for skull radiographs?

The aim of the present study is to assess if skull fracture is a useful predictor of intracranial abnormality in children with minor head injury (MHI) and to evaluate the usefulness of skull radiographs. Retrospective review of CT scans and skull X-rays (SXR) of children <14 years of age with blunt head injury and correlation with the Glascow Coma Score definition of MHI (GCS > 12/15 or > 9/11) over a 1-year period was done. Three-hundred and eighty-one patients were included with a mean age of 6 years. Thirty-one percent of patients had intracranial abnormality. Forty-nine percent of all patients had fractures either on CT or SXR and 49% of these had intracranial abnormality on CT. Eighty-five percent of patients with drainable collections had associated fractures. Twenty-three percent of MHI had abnormalities on CT, of which 32% were drainable collections. All patients with MHI who had drainable collections showed a fracture. Some protocols for paediatric head injury recommend CT for all patients while others rely on clinical indicators. In developing countries, CT is neither widely available nor accessible, and preselection of patients is necessary. We demonstrated that omitting CT in MHI could result in missed intracranial abnormalities. All MHI with drainable collections had fractures. Fractures identified on SXR can be added to the clinical indications for CT in MHI and can improve detection of 'silent' drainable collections.