Original Article
Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly

https://doi.org/10.1016/j.jpedsurg.2015.08.064Get rights and content

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 10 year 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 1 week to 12.4 years 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).

Conclusion

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.

Section snippets

Objectives

Our aims were to identify pediatric patients at our institution with a presenting diagnosis of an isolated skull fracture, and to determine their outcomes. Using this information we planned to evaluate whether inpatient observation was necessary, determine health care costs associated with an isolated skull fracture, and formulate a management algorithm. We hypothesized that an isolated skull fracture in a neurologically intact pediatric patient would correlate with a very low risk of

Materials and methods

After obtaining IRB approval, we performed a single center retrospective review at a free-standing major metropolitan pediatric level-one trauma center. The medical records of all pediatric trauma patients presenting to the emergency department with ICD-9 codes indicating head trauma (803.00, 803.01, 803.06, 803.09, 854.00, 959.00, 660890, and 727915) were reviewed from June of 2004 through June of 2014.

Inclusion criteria included patients presenting to the emergency department with CT of the

Results

Over the 10-year period examined, 163 patients were identified as having a head trauma with a skull fracture. There were 71 patients that satisfied the selection criteria that were outlined for the study. Of these patients 56% were male and 44% were female. Patient ages ranged from 1 week old to 12.4 years old with an average age of 19 months. Sixty of the total seventy-one patients (85%) were aged less than three years of age (Fig. 2).

The majority (77.5%) of patients were admitted for inpatient

Discussion

Traumatic brain injuries are one of the most common serious injuries that pediatric patients sustain [23]. We identified that patients with a normal neurologic exam in the setting of an isolated skull fracture often are without associated intracranial injury or significant risk of long-term sequalae. CT scan imaging allowed us to identify those patients that had isolated non-depressed skull fractures. It was a valuable tool in assessing both the degree of fracture and any other intra-cranial

Conclusion

In conclusion, inpatient neurological observation is unnecessary for pediatric patients with isolated skull fractures, and normal neurological examinations. We propose that these patients may be safely discharged home with outpatient follow up as long as there is no concern for NAT (Fig. 4). Appropriate discharge of low risk patients would be expected to decrease health care costs associated with pediatric blunt head trauma without negatively impacting patient care.

Author contribution

  • Brian P. Blackwood: first author, literature search, writing (65%), study design, data collection, data analysis and interpretation.

  • Jonathan F. Bean: second author, literature search, writing (35%), study design, data collection, data analysis.

  • Corinne Sadecki-Lund: data collection and interpretation.

  • Irene B. Helenowski: data analysis.

  • Rashmi Kabre: data interpretation, manuscript preparation.

  • Catherine J. Hunter: study design, data analysis, data interpretation, manuscript preparation.

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