59 - Suspicion of palpable skull fractures on physical examination and subsequent computed tomography findings of depressed skull fractures and traumatic brain injuries

Poster Number: 59
Publication Number: 59.104

Silvia Bressan, University of Padova, Padova, Veneto, Italy; Daniel J. Tancredi, University of California, Davis, School of Medicine, Sacramento, CA, United States; Charlie Casper, University of Utah School of Medicine, Draper, UT, United States; Liviana Da Dalt, University of Padova, Padova, Veneto, Italy; Nathan Kuppermann, University of California, Davis, School of Medicine, Sacramento, CA, United States

Background: Clinical suspicion of palpable skull fractures on physical examination puts children with minor blunt head trauma at high risk of underlying traumatic brain injuries (TBIs). Clinical signs of palpable skull fractures, however, have moderate interobserver agreement between clinicians. Therefore, their usefulness in identifying skull fractures that are depressed or displaced (and associated with TBIs) is unclear.

Objective: We aimed to explore the frequency of depressed or displaced skull fractures on computed tomography (CT) in children with palpable scalp findings suggestive of skull fractures. As a secondary objective we aimed to describe the frequency of TBIs associated with these physical findings.

Design/Methods: This was a secondary analysis of a large, prospective, multicenter cohort study enrolling 42,412 children < 18 years old with Glasgow Coma Scale scores of 14 or 15 following blunt head trauma across 25 emergency departments in the Pediatric Emergency Care Applied Research Network (PECARN), between June 2004 and September 2006. A palpable skull fracture was defined per the assessment of the treating clinician documented on the case report form of the parent study.

Results: Signs of palpable skull fractures were reported in 368/10,698 (3.4%) children younger than 2 years, of whom 273 (74.2%) underwent CT, and in 676/31,613 (2.1%) of those 2 years and older, of whom 486 (71.9%) underwent CT. Of these, 56/273 (20.5%) and 30/486 (6.2%) had depressed/displaced skull fractures. In contrast, in children without these physical findings, 34/3047 (1.1%) of the younger group and 63/11,130 (0.6%) of the older group had depressed/displaced skull fractures (rate difference 19.4%; 95%CI 14.6-24.2 and 5.6%; 95%CI 3.5-7.8 for younger and older children, respectively). Among the younger group, TBIs on CT were found in 73/273 (26.7%) children with signs of palpable skull fractures on examination and in 189/3047 (6.2%) of those without (rate difference 20.5%; 95%CI 15.2-25.9). In the older group, TBIs on CT were found in 61/486 (12.6%) for those with signs of palpable skull fractures on examination versus 424/11,130 (3.8%) of those without (rate difference 8.7%; 95%CI 6.1-12.0).Conclusion(s): Children with palpable signs of skull fractures following minor blunt head trauma have higher frequencies of depressed/displaced skull fractures and TBIs on CT than those without these signs. However, the discriminatory ability of the scalp examination is suboptimal and could be enhanced by direct bedside visualization of fracture characteristics, such as through skull ultrasound.