What is Pediatric Skull Fractures?
Head injuries can sometimes lead to a broken skull and are a frequent reason for severe health issues and death in children. Such injuries are often seen in the Pediatric Emergency Department and in primary healthcare settings. Children are more likely to get head injuries and broken skulls compared to adults. During infancy, the size of a child’s head is about 18% of their whole body, but this decreases to almost 9% when they reach adulthood. Generally, a child’s skull is thinner and more flexible, meaning it provides less protection to the brain.
What Causes Pediatric Skull Fractures?
Head injuries and skull fractures can happen either by accident or as a result of non-accidental injuries. Commonly, these injuries happen because of falls. Other causes can be car accidents, sports-related injuries, or other direct hits to the head.
Sometimes, newborns can have a specific type of skull fracture known as a “ping-pong” fracture due to injuries during birth. It’s vital for doctors and health professionals to identify non-accidental injuries, especially in kids who come to the hospital with a head injury or skull fracture.
Moreover, it’s particularly crucial to do so in infants who are not yet mobile. A comprehensive review of 12 studies about skull fractures due to abuse showed that a skull fracture points towards suspected or confirmed abuse in about 20.1% of cases.
Risk Factors and Frequency for Pediatric Skull Fractures
Head injuries are quite common in children and are the leading cause of severe trauma. Thankfully, the majority of these cases, around 80% to 90%, are not serious. Only a small number of these injuries are life-threatening or need surgery. The rate of skull fractures in children after a head injury is estimated to be between 2% and 20%. However, more research is needed to get more precise numbers. Skull fractures are more common in children under two years of age who have experienced head trauma. Fractures of the upper part of the skull, or the “skull cap”, are more common than those at the base of the skull.
- Head injuries frequently occur in children and are the main cause of severe trauma.
- About 80% to 90% of head injuries are mild, with only a small percentage needing surgical intervention or being life-threatening.
- The occurrence of skull fractures in children after a head injury is estimated to be between 2% to 20%. More research is necessary for accurate numbers.
- Skull fractures are more common in children under the age of 2 who have suffered a head injury.
- Skull cap fractures are more common than fractures at the base of the skull.
Signs and Symptoms of Pediatric Skull Fractures
When a child comes in with a head injury, there are several things a healthcare professional can do to determine the likelihood of a skull fracture or severe brain injury.
Key factors to consider include the timing and details of the injury. If there’s a delay in getting treatment, that could be a sign of non-accidental harm. Other important details include how the injury happened (such as a fall, collision or car accident), who saw it happen, and other specifics related to the injury. This could be facts about a fall (like how high it was or what surface they fell on) or details about a car accident (like whether the patient was thrown from the car). Knowing what condition the child was in immediately after the injury and how they’ve been doing since can also be crucial.
It’s also important to look at the child’s past medical history. This can include whether they have disorders that affect their bones, like osteogenesis imperfecta, or bleeding disorders like hemophilia. It’s also necessary to know what medications they are on.
Physical examination should then follow a trauma protocol if severe injury is suspected. This involves a primary, secondary and tertiary survey. The Glasgow coma scale is used to see how alert the patient is, but should be modified for younger children. The head should be examined for swelling that changes when pressure is applied (which could indicate a fracture), an actual fracture or cuts. If the fontanelle (the soft spot on a baby’s head) is still open, the head circumference should be increased as this can show bleeding or swelling in the brain.
It’s also recommended to check the ears, nose, and throat for signs of a basal skull fracture. These can include bleeding in the middle ear, fluid leaking from the nose or ears, a bruise behind the ear, or ring sign, which is when fluid that’s mixed with blood separates, creating a clear ring around the blood when dropped onto filter paper. But the ring sign can be misleading, as blood that’s mixed with water or saline can do the same thing.
A neurological and cranial nerve examination can also be performed to look for signs of increased pressure in the skull. A bruising or other injuries from top to bottom examination should also be carried out in case there are other traumatic injuries or if non-accidental harm is suspected. Always consider whether the given explanation of how the injury happened matches up with the child’s age and the clinical findings.
Testing for Pediatric Skull Fractures
If a skull fracture is suspected, different imaging methods can be used to confirm it. These include X-rays, CT scans, ultrasound, and MRI. According to current guidelines, a CT scan is generally the first option, although X-rays may be used in certain cases where a child with a possible head injury has no symptoms. However, it’s important to note that CT scans involve exposure to ionizing radiation, which may pose a higher risk of cancer in the future, especially in young children. Additionally, CT scans may require sedation or anesthesia in children, which carries its own risks.
Doctors use various guidelines to decide when a child with a head injury needs a CT scan. Three such rules are the PECARN head injury algorithm, the CATCH rule, and the CHALICE rule. When signs of a skull fracture – such as signs of a basal skull fracture, a noticeable fracture, swelling, bruising, or a bump larger than 5 millimeters, or suspicion of a depressed skull fracture – are present, a CT scan is generally recommended.
In some cases, an ultrasound might be used to identify skull fractures in younger patients, but this is not widely used and more study is needed to understand its effectiveness. MRI might also be a good option because it doesn’t involve any radiation exposure, but its use can be limited because it’s not always available immediately when needed.
After a patient has been diagnosed with a skull fracture, a CT scan doesn’t usually need to be repeated, unless symptoms become worse. In some cases of suspected head trauma in young children and infants, further investigations might be called for to rule out non-accidental injury. In these cases, checks for additional old fractures might be needed, and X-rays might be used along with CT scans, because they are more sensitive for detecting old fractures.
Treatment Options for Pediatric Skull Fractures
How skull fractures are treated depends on where the fracture is, what type it is, and if there’s any injury to the brain underneath. Simple linear fractures, which are straight break lines without any brain injury, usually don’t need any treatment. There is a range of opinions on whether people should be closely watched in a hospital or clinic, and whether skull fractures should be dealt with like concussions. In fact, one study showed that when we do need to treat fractures, it’s often not because of the fracture itself, but rather because there’s another injury. Younger people and those with symptoms should be admitted to the hospital and watched closely.
However, lots of studies have said that children with simple fractures who aren’t showing any symptoms can safely be sent home from the emergency room. In each of these cases, a CT scan was done to confirm there was no brain injury underneath the fracture.
Fractures in the frontal bone, or the front of the skull, are more likely to need repair from a neurosurgeon, a brain surgery specialist. A depressed fracture, where the bone is pushed in, usually needs to be treated too. Neurosurgeons would consider lifting a depressed fracture if it’s pushed in more than 5 millimeters, if the protective layer around the brain is hurt, if there’s a blood clot, or if the fracture is severely contaminated. An open fracture, where the wound is open and visible, will likely need to be cleaned out and treated with antibiotics. Basal skull fractures, which are fractures at the base of the skull, usually don’t need any treatment unless there’s ongoing leakage of brain fluid. A patient with this type of fracture should not have a tube down their nose. There’s currently no evidence that giving patients antibiotics early prevents brain infection, even though a leak of brain fluid might increase the risk of getting it.
What else can Pediatric Skull Fractures be?
- Damage to the brain tissue
- Bleeding between the skull and outer layer of the brain
- Conditions affecting the frontal part of the brain that can alter behavior and thinking
- Seizures that can affect the whole body with intense muscle contractions
- Excess fluid build-up in the brain, causing pressure and swelling
- Fractures where the skull is cracked and indented
- Diseases caused by abnormal proteins in the brain
- Pus-filled infection between the brain cover and the skull
- Bleeding between the skull and the scalp
Possible Complications When Diagnosed with Pediatric Skull Fractures
When a child experiences a skull fracture, several complications may emerge. These are:
- Seizures
- Blood clots in the brain’s veins (Venous sinus thrombosis)
- Bleeding within the brain (Intracerebral bleed)
- Meningitis, which is an infection of the brain and spinal cord coverings (only if the fracture is open)
- Growing skull fracture, which is when a fracture line in the skull continues to widen over time
