title: Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly.
abstract: BACKGROUND
  Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly.
  
  
  METHODS
  We performed a single center 10year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention.
  
  
  RESULTS
  Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1week to 12.4years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p=0.7474, p=0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p<0.0001).
  
  
  CONCLUSIONS
  Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.
authors.affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department of Surgery, 225 E. Chicago Ave, Box 63, Chicago, IL 60611; Rush University Medical Center, Department of General Surgery, 1750W. Harrison Street, Suite 785, Chicago, IL 60612. Electronic address: brian_p_blackwood@rush.edu.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Blackwood
authors.affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department of Surgery, 225 E. Chicago Ave, Box 63, Chicago, IL 60611. Electronic address: jfbean@uic.edu.
authors.forename: Jonathan F
authors.initials: JF
authors.lastname: Bean
authors.affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department of Surgery, 225 E. Chicago Ave, Box 63, Chicago, IL 60611. Electronic address: CSadeckiLund@luriechildrens.org.
authors.forename: Corinne
authors.initials: C
authors.lastname: Sadecki-Lund
authors.affiliation: Northwestern University Feinberg School of Medicine, Department of Pediatrics, 310 E. Superior St., Searle #4-490, Chicago, IL 60611. Electronic address: i-helenowski@northwestern.edu.
authors.forename: Irene B
authors.initials: IB
authors.lastname: Helenowski
authors.affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department of Surgery, 225 E. Chicago Ave, Box 63, Chicago, IL 60611. Electronic address: rkabre@luriechildrens.org.
authors.forename: Rashmi
authors.initials: R
authors.lastname: Kabre
authors.affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department of Surgery, 225 E. Chicago Ave, Box 63, Chicago, IL 60611; Northwestern University Feinberg School of Medicine, Department of Pediatrics, 310 E. Superior St., Searle #4-490, Chicago, IL 60611. Electronic address: chunter@luriechildrens.org.
authors.forename: Catherine J
authors.initials: CJ
authors.lastname: Hunter
mesh_terms: D002641:Chicago; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009460:Neurologic Examination; D010043:Outcome and Process Assessment, Health Care; D012189:Retrospective Studies; D012887:Skull Fractures / Q000175:diagnosis / Q000191:economics / Q000209:etiology / Q000628:therapy*; D019564:Unnecessary Procedures / Q000191:economics*; D057832:Watchful Waiting / Q000191:economics*; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000191:economics / Q000209:etiology / Q000628:therapy*
keywords: Costs; Isolated; Management; Pediatric trauma; Skull fracture