Pediatric Cranial Vault Fractures: Analysis of Demographics, Injury Patterns, and Factors Predictive of Mortality.
BACKGROUND
Pediatric cranial vault fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts with potential implications on the development of the brain and craniofacial skeleton, and require unique considerations for management and treatment outcomes.A detailed analysis of the characteristics and outcomes of pediatric cranial vault fractures remains understudied in this population. Thus, the aim of this study was to characterize the demographics, injury patterns, operative interventions, concomitant injuries, and factors predictive of mortality in pediatric patients sustaining cranial vault fractures.


METHODS
A retrospective review of patients less than 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with skull fractures was performed. All patients were included regardless of treating specialty, treatment modality, or inpatient status. Patients were stratified into 3 groups (age < = 5 yrs, 5.1-11 yrs, and >11 yrs). ZIP codes were mapped using ArcGIS 10.2 Software (ESRI Inc, Redlands, CA) with ZIP code shapefiles from ESRI's ArcGIS Online. Socioeconomic and demographic variables at the ZIP code level were linked to each geocoded location using the United States Census Bureau summary files, and spatial clusters of injury were performed using GeoDa to conduct a test of local indicator of spatial autocorrelation. Statistical analysis was performed using the SPSS version 17 (SPSS Inc, Chicago, IL).


RESULTS
A total of 923 consecutive patients met the inclusion criteria for the study. Caucasian (P < 0.001) males (P = 0.055) were most likely to sustain cranial vault fractures. The average age at injury was 5.97 years. Falls (53.7%) were the most common cause of injury across all age groups, followed by collisions (20.8%), with falls being more common in the youngest age group (< = 5 yrs), and collisions being more common in the older age groups. Direct objects to the head had the highest rate of surgical intervention (P < 0.001). Parietal bone fractures were more frequent in the youngest age group, while frontal and temporal bone fractures were more common in the older age groups. Increasing age was an independent predictor of the need for surgical intervention (P < 0.0001). The overall incidence of blindness and hearing loss was low, and increased with increasing age. Patients with fractures as a result of violent mechanisms were more likely to come from highly impoverished zip codes, compared with patients with nonviolent mechanisms of injury (19.6% versus 8%). Overall mortality was low (2.9%). Temporal bone fractures had the greatest risk of mortality (P < 0.001) with age > = 5 years being an independent predictor of mortality (P < 0.001). Victims of falls, and patients with associated gastrointestinal or musculoskeletal injuries, had a statistically significant increased chance of survival, whereas victims of collisions and patients with concomitant cervical spine, cardiothoracic, or respiratory injuries had a significantly increased risk of death.


CONCLUSIONS
Pediatric cranial vault fracture injury patterns are significantly correlated with demographics, mechanisms of injury, presence and type of concomitant injuries, need for surgical intervention, and mortality. Although the need for operative intervention and overall mortality is low, these variables play significant roles in portending prognosis, and an understanding of the metrics presented herein will enable practitioners optimize management and treatment in this unique patient population.
*Division of Pediatric Surgery, Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA †Section of Pediatric Plastic Surgery, Division of Plastic Surgery, Albany Medical Center, Albany, NY ‡Department of Neurological Surgery §Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA ||Division of Emergency Medicine, University of California San Diego, San Diego, CA.
Oluwaseun A
OA
Adetayo
Sanjay
S
Naran
Christopher M
CM
Bonfield
Margaret
M
Nguyen
Yue-Fang
YF
Chang
Ian F
IF
Pollack
Joseph E
JE
Losee
D000058:Accidental Falls / Q000706:statistics & numerical data; D000063:Accidents, Traffic / Q000706:statistics & numerical data; D000293:Adolescent; D000367:Age Factors; D001766:Blindness / Q000453:epidemiology; D002574:Cervical Vertebrae / Q000293:injuries; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005147:Facial Bones / Q000293:injuries; D005260:Female; D005624:Frontal Bone / Q000293:injuries; D034381:Hearing Loss / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D009104:Multiple Trauma / Q000453:epidemiology; D010294:Parietal Bone / Q000293:injuries; D011203:Poverty / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012887:Skull Fractures / Q000453:epidemiology* / Q000401:mortality; D015996:Survival Rate; D013701:Temporal Bone / Q000293:injuries; D014481:United States / Q000453:epidemiology; D014754:Violence / Q000706:statistics & numerical data