Linear nondisplaced skull fractures in children: who should be observed or admitted?
OBJECTIVE
In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed.


METHODS
After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children's hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus.


RESULTS
Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7-395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2-43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit.


CONCLUSIONS
Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.
Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas.
Eliel N
EN
Arrey
Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas.
Marcia L
ML
Kerr
Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas.
Stephen
S
Fletcher
Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas.
Charles S
CS
Cox
Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas.
David I
DI
Sandberg
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003244:Consciousness Disorders / Q000453:epidemiology; D004636:Emergency Service, Hospital; D005260:Female; D015600:Glasgow Coma Scale; D017048:Health Care Costs; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008499:Medical Records; D010343:Patient Admission / Q000191:economics / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000191:economics / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012887:Skull Fractures / Q000191:economics / Q000453:epidemiology* / Q000473:pathology*; D013781:Texas / Q000453:epidemiology; D057832:Watchful Waiting / Q000191:economics
CMHH = Children’s Memorial Hermann Hospital; CONSORT = Consolidated Standards for Reporting of Trials; CPS = Child Protective Service; LOS = length of stay; MOI = mechanism of injury; NDSF = nondisplaced skull fracture; linear skull fracture; nondisplaced; pediatric head trauma