Re-Examining the Brain Injury Guidelines in Pediatric Traumatic Brain Injury: Can Simple Isolated Non-Displaced Skull Fractures be Treated as a BIG-1 Injury?

Children with mild traumatic brain injury (TBI) often receive unnecessary imaging studies, hospital admissions, and interhospital transfers leading to avoidable burdens to patients, caregivers, and health systems. The Brain Injury Guidelines (BIG) consider a non-displaced skull fracture as a BIG-2 injury warranting hospitalization. In our clinical experience, patients with simple isolated non-displaced linear skull fractures seldom develop TBI-related complications. In this study, we evaluated the need for hospital admission for simple isolated linear skull fractures by examining the occurrence of clinically important TBI (ci-TBI) and patient outcome. We performed a retrospective study evaluating pediatric TBI admissions from 2018 to 2023 using an institutional registry of TBI patients requiring neurosurgery consultation. Patients included in our study cohort were 17 years and younger at injury, had a head computed tomography with an isolated skull fracture and a Glasgow Coma Scale (GCS) of 14 to 15. We excluded patients who had an intracranial injury (ICI), fractures extending into the skull base, or crossing the sagittal sinus. We reviewed medical records to identify the presence of ci-TBI: ICI resulting in death, neurosurgical intervention, intubation for more than 24 h, or hospital admission for at least 2 nights due to TBI. Repeat imaging studies obtained were reviewed to assess the progression of injury and association with clinical deterioration. Patient outcome was evaluated with the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable statistics were calculated for continuous variables and 95% confidence intervals were calculated using the Clopper-Pearson exact method for proportions that were very close to 0 or 1 and the Wilson score interval for small-to-moderate proportions. A total of 804 subjects were analyzed, and 402 (50.0%) patients had a BIG-2 injury. A total of 247 of these BIG-2 patients (61.4%) had a simple, non-displaced fracture, and no associated ICI; 198 of these patients (80.2%) were transferred from referring hospitals. In both primary admissions and transfers, no significant injury progression on imaging was noted, no neurosurgical intervention occurred, and no patient had ci-TBI (0/247; 95% CI: 0% to 1.5%). Six-month GOS-E was available in a subset (53.8%) of patients: 98.5% were discharged home and had a favorable outcome (defined as GOS-E 5 to 7). ci-TBI rarely develops in children with simple isolated non-displaced skull fractures indicating that hospital admission and inpatient observation may not be necessary. In the context of the BIG, these patients can be considered for re-classification to a BIG-1 injury, which can reduce interhospital transfer and admission rates following implementation, while maintaining patient safety. A revised BIG classification for pediatric injuries is proposed.