linear nondisplaced skull fractures in children: who should be … · traumatic brain injuries...

$: Linear nondisplaced skull fractures in children: who should be … · traumatic brain injuries amount to more than $1 billion in hospital charges each year.16 While an overwhelming$
clinical articleJ neurosurg Pediatr 16:703–708, 2015

Head trauma is an important cause of morbidity and mortality in the pediatric population of the US, with an annual death toll estimated at more than

3000 patient deaths and well over 650,000 emergency de-partment visits annually.12,19 It is estimated that pediatric traumatic brain injuries amount to more than $1 billion in hospital charges each year.16 While an overwhelming majority of these head injuries are considered mild, minor head injuries represent almost 400,000 emergency depart-ment visits annually.1,19 Livingston et al. estimated that if

patients with isolated minor head injuries, a negative head CT scan, and no other intracranial pathologies were dis-charged from the emergency department, there could be a potential decrease in more than 500,000 hospital admis-sions each year.9 Although the idea that patients with iso-lated nondisplaced skull fractures (NDSFs) can be safely discharged home with no adverse neurological effects is generally well accepted, this is not the common practice among many institutions.

Linear NDSFs are common in pediatric patients after

abbreviations 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.submitted January 23, 2015. accePted April 28, 2015.include when citing Published online September 4, 2015; DOI: 10.3171/2015.4.PEDS1545.

Linear nondisplaced skull fractures in children: who should be observed or admitted?eliel n. arrey, bs, marcia l. Kerr, rn, stephen Fletcher, do, charles s. cox Jr., md, and david i. sandberg, md

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

obJect In this study the authors reviewed clinical management and outcomes in a large series of children with iso-lated 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.http://thejns.org/doi/abs/10.3171/2015.4.PEDS1545Key words nondisplaced; linear skull fracture; pediatric head trauma

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head trauma and do not require neurosurgical interven-tion. The disposition of patients with NDSFs varies by institution and even within the same institution. Some patients are admitted to a hospital inpatient unit or kept for 23-hour observation, and others are discharged home from emergency departments.2,6,8,10,15,17 The objective of this study was to review disposition data on children with NDSFs at a single, busy pediatric trauma center and to assess factors associated with the observation and hospi-talization of these patients as well as costs of care.

methodsAfter obtaining institutional review board approval,

we retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at Children’s Memorial Her-mann Hospital (CMHH) in Houston, Texas, between Jan-uary 2009 and December 2013. All patients had received a CT scan at the time of diagnosis that clearly showed the NDSF in the bone window and any other intracranial pa-thology in the brain window. If a patient arrived at our center with only plain skull radiographs that demonstrated a fracture, then a CT scan was performed upon arrival. Patients with a single nondisplaced calvarial fracture were included in this study. Patients with isolated NDSFs and simultaneous non-CNS injuries (such as orthopedic inju-ries) were included in the study. Linear skull fractures that crossed a suture line but did not have associated intracra-nial hemorrhage or other exclusion criteria were included. Patients with open or comminuted skull fractures, intra-cranial hemorrhage, multiple skull fractures, or pneumo-cephalus (defined as intracranial air) were excluded. Any quantity of intracranial hemorrhage or pneumocephalus, no matter how small, was sufficient for exclusion from this study. Patients with any other intracranial or cervical pa-thology such as hydrocephalus, brain tumors, head or neck vascular injuries, or cervical spine fractures were also ex-cluded. Notes from patient encounters such as emergency department visits, neurosurgical consults, hospital admis-sion notes, social work notes, and postdischarge follow-up visits were reviewed. To assess costs associated with patient care, we collected data on the admitting hospital unit for each patient, the hospital length of stay (LOS), and means of arrival of each patient to the hospital.

resultsPatient demographics

A total of 948 patients presented to CMHH between January 2009 and December 2013 with a diagnosis of traumatic brain injury. Of these 948 patients, 326 met in-clusion criteria for this study. Figure 1 is a Consolidated Standards for Reporting of Trials (CONSORT) profile de-fining these patients’ exclusion criteria. One hundred thir-ty-four patients were excluded because fractures were de-pressed, multiple, or comminuted. Thirteen patients were excluded because fractures were open. Forty-three addi-tional patients were excluded for pneumocephalus, 133 for intracranial hemorrhage, and 96 because a skull fracture was not definitive on review of imaging studies. Patient

demographics are summarized in Table 1. The majority of the patients were male (59%), and the largest ethnicity represented was patients of Hispanic descent (45%). Me-dian age at time of evaluation was 19 months (age range 2 weeks to 15 years).

hospital encounterOf the 326 patients who met inclusion criteria, 56% (n

= 184) were placed under 23-hour observation status, 27% (n = 87) were admitted to the hospital floor, and 17% (n = 55) were discharged from the emergency department. No discharged patient in this study required repeat admission. Less than 16% (n = 50) were followed up in the pediatric neurosurgery clinic after discharge. All 50 of these pa-tients were neurologically intact at the time of the follow-up visit. Seventy-nine percent (n = 257) of the patients were transferred from another institution. Seventy-six per-cent (n = 42) of the patients who were discharged from the emergency department were initially transferred from a community hospital to CMHH. Eighty-five percent (n = 278) of the patients arrived at the hospital by ambulance, 11% (n = 36) arrived by car, and 4% (n = 12) were airlifted by helicopter to the hospital.

According to the history provided at the time of pre-sentation to the emergency department, 14% of patients (n = 45) had altered mental status or loss of conscious-ness, 21% (n = 68) had at least 1 episode of vomiting after head trauma, and 2% (n = 8) had witnessed seizures or seizure-like activity after head trauma. No patient had any neurological deficits at the time of admission, and none required any neurosurgical intervention. The mean hos-pital LOS for patients admitted to the inpatient unit was 46 hours, and the mean LOS for patients placed under 23-hour observation status was 18 hours (Table 2). The LOS for patients in the inpatient unit ranged from 7 hours to 16 days. The longest time a patient spent in the observation unit was 43 hours.

Child protective service (CPS) involvement was a cause of extended hospitalization in 7% (n = 24) of patients in this study. Three percent of patients (n = 11) experienced extended hospitalization because of other injuries. Addi-tional injuries in this patient group are listed in Table 3.

mechanism of injuryMechanism of injury (MOI) for patients who met inclu-

sion criteria is summarized in Table 4. Falls were the most common cause of head injury across all patient groups. A total of 230 patients (71%) sustained their head injury after a fall. Seven percent (n = 23) of these were specifically due to a fall from a shopping cart. The 3 most common MOIs sustained by patients placed under 23-hour observa-tion were falls (n = 143), dropped by a caregiver (n = 12), and object to the head (n = 9). For patients admitted to the hospital floor, the most common MOIs were falls (n = 46), possible nonaccidental trauma (n = 20), and object to head (n = 6).

location of skull FractureFracture locations are summarized in Table 5. Over-

all, the most common locations for an NDSF in this study were the occipital bone (n = 126), the parietal bone (n =


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102), and the frontal bone (n = 58). Four percent of the pa-tients had a nondisplaced frontal bone that extended to the orbital rim (n = 14) and 5% (n = 17) had a single fracture involving 2 bones. There were no frontal bone fractures that involved the frontal sinuses in this study.

hospital cost assessmentThe current room charge per hour and staffing at

CMHH’s inpatient unit is $782 per day, not including sup-plies and medications. The observation unit can cost as much as $1283 if a patient spends up to 24 hours in ob-servation. The average LOS for patients under observation in this study was 18 hours, and 46 hours for patients in the inpatient unit, adjusting the mean costs to $962.25 and $1498.83 respectively.

discussionWhile previous studies have reviewed large series

of children with skull fractures, this is the largest study specifically focusing on linear NDSFs and excluding more serious injuries. We hypothesized that some hos-pitalizations in these patients can be safely avoided and

Fig. 1. CONSORT profile defining the patient exclusion criteria. The arrows represent the flow of patients throughout this process.

table 1. summary of patient demographics

Demographics Value

Age Median 19 mos Range 2 wks–15 yrsSex (M/F) 193/133Race/ethnicity African American 27 Asian 16 Caucasian 126 Hispanic 148 Other* 9Insurance Private 119 Medicaid 189 None 18

* Racial groups represented by only 2 patients or fewer.


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that avoiding such hospitalizations could render consid-erable cost savings. The majority of the patients in this retrospective study were male, Hispanic, and insured by Medicaid. These findings are reflective of the community our hospital serves. The most common MOI in our study was falls, which has been noted as a predominant cause of skull fractures in previous publications.3,4,10 In their large series, Bonfield et al. noted that high-impact injuries such as motor vehicle collisions or objects to the head have a higher potential to cause depressed or open skull fractures that may require neurosurgical intervention.3 Nonetheless, patients with isolated NDSFs require no neurosurgical in-tervention and may not require hospitalization.

The most important finding of this study, as expected, was that none of the 326 patients had a neurological defi-cit at any point in their management, and none required neurosurgical intervention. An obvious limitation of these data is that only 16% of patients had follow-up outpatient visits after their hospitalization. This low follow-up rate is directly related to our practice pattern, which does not include mandatory follow-up appointments in this popula-tion. At our hospital, when a patient with an NDSF is dis-charged from the emergency department or hospital, the parents are told to bring the patient back to the emergency department or outpatient clinic only if new signs or symp-toms arise. While it is theoretically possible that some of the patients without follow-up had new signs or symptoms that were assessed in outside hospitals, it is highly unlikely that this happened in a large number of patients.

Given the fact that no patient with an NDSF required neurosurgical intervention and none had a neurological deficit, the obvious question is why only 17% of patients were discharged from the emergency department and the remainder were hospitalized or kept for 23-hour inpatient observation. There are a variety of factors that influenced

this statistic. Certainly, any patient with suspicion of non-accidental injury cannot be sent home to a potentially un-safe environment, as nonaccidental injury claims the lives of more than 280 children each year in the US.5 In this co-hort, 7% of patients required extended hospitalization due to CPS input. However, many of the observation patients were held in observation status pending a nonacciden-tal trauma evaluation without specific CPS involvement. Four percent of patients required extended hospitalization due to non-CNS injuries. Other possible explanations for hospitalization or 23-hour observation were episodes of vomiting (21%), history of altered mental status (14%), or possible seizure activity (2%). Some of these symptoms, as well as headaches, dizziness, and poor memory or con-centration, may persist for days to weeks in patients after minor head injuries.8,20,21 While these symptoms do not typically portend the need for neurosurgical intervention in patients who are neurologically intact and do not have intracranial hemorrhage or other injury, practitioners are understandably reluctant to send patients home who are symptomatic soon after a head trauma. Some emergency medicine guidelines suggest that children less than 2 years of age should be observed for 4 to 6 hours in the hospital and discharged if asymptomatic and neurologically intact after this period of observation.8

Seventy-eight percent of patients were transferred from outside hospitals, either by ambulance (85%) or even he-licopter (4%), and many parents presumably arrived with the expectation that a higher level of care and possibly intervention would be required for their child. It is often easier for practitioners to simply admit these patients to the hospital unit or keep them for 23-hour observation status, particularly when patients arrive in the middle of the night, rather than explain to parents that such transfers were not necessary. While patients should be transferred from com-munity hospitals if treating physicians do not feel com-fortable with their management, clearly there is room for improvement in educating some physicians in these hos-pitals about the natural history of isolated NDSFs and the unlikely need for intervention.

Not all community hospitals have a neurosurgical team onsite to manage a patient with a skull fracture, and some

table 2. summary of hospital los

Admitting Hospital Unit Mean Hospital LOS (hrs) Range (hrs)

Inpatient unit 46 7–39523-hr observation 18 2–43

table 3. Patients with other injuries

Type of Injury LOS (hrs)

Rt open tibia-fibular fracture, rt scapular wing fracture, tiny Grade I liver laceration, multiple mild lt pulmonary con tu-sions & small amount of free fluid in pelvis

37

Lt humerus film: displaced mid-shaft humerus fracture 46Rt orbital wall fracture, lt upper neck emphysema & masticator space emphysema w/o obvious skin laceration 67Rt 5th rib fracture & possible fracture of the anterolateral aspect of lt 7th rib w/ unknown MOI 67Rt distal radius Salter II fracture 70Rt superior inferior pubic ramus fracture, rt nondisplaced clavicle fracture, rt oblique tibia-fibular fracture 74Lt humeral fracture & multiple fractures of distal long bones & ribs 83Comminuted fracture of lt iliac wing w/ extension to lt sacroiliac joint 95Lt lower extremity soft-tissue avulsion w/ joint exposure 182Grade 3 liver laceration, Grade 2 spleen laceration, rt lower lobe contusion, small hemothorax, and rt pneumothorax 245Grade 2 laceration of spleen, laceration of body of pancreas, rt adrenal hematoma, healing rt 11th rib fracture, Grade

3 colonic injury, & Grade 1 duodenal injury395


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centers are uncomfortable or not equipped to care for children with head injuries. Thus, some community hos-pitals have no other option but to transfer patients with skull fractures to higher-level trauma centers where these patients can be properly observed and managed. Placing a patient under observation status assumes that the observa-tion will “uncover a reasonable percentage of occult inju-ries not found on diagnostic testing amenable to prompt intervention, thereby reducing complications and death.”9 A multicenter retrospective review of patients admitted for minor head injuries reported that more than a third of the patients were missing documented observation.18 Cur-rent emergency guidelines strongly encourage community hospitals to initiate rapid referrals to pediatric trauma cen-ters whenever ongoing reassessment and definitive man-agement of admitted patients with head trauma cannot be met by the community facility.8 An important finding in our study was that 76% (n = 42) of patients discharged upon arrival to our center had been transferred from an outside hospital for a higher level of care. As most hospital transfers employ the use of ambulance and helicopter ser-vices, these transfers create a significant financial burden for families and insurance companies. As part of our cost assessment, we reviewed the standard charge rates by the Houston Fire Department and Life-Flight helicopter ser-vices in our area. The Houston Fire Department’s ambu-lance service cost $1000 (base rate) plus $13 per mile, and

the Life-Flight helicopter service cost $11,902.82 (base rate) plus $118.98 per mile.11,13 At least in some cases, it is clear that these hospital transfers, and their extensive costs, were not medically necessary. In an effort to minimize interhospital transfers and the use of hospital resources, the Primary Children’s Hospital in Salt Lake City, Utah, institutionalized a “Management Algorithm for Isolated Skull Fractures” in January 2012.10 The new guideline criteria for admission included vomiting, abnormal neuro-logical examination results, possible nonaccidental injury, and high-energy injury mechanisms. These guidelines recommended rapid discharge of patients with an iso-lated skull fracture, a normal neurological examination, no high-energy MOI, and no other non-CNS injuries. In their prospective study on the impact of these new guide-lines, Metzger et al. were able to identify an 18% decrease in overall admission rates of patients with isolated skull fractures with no compromise to patient safety.10 Although this was a “modest” decrease in admission rates compared with years prior, Metzger et al. do agree that “there [still] exists the potential to further reduce the admission rates…for these patients.”10

conclusionsIn conclusion, 23-hour observation or hospitalization

for many children with NDSFs is costly and not always

table 4. mechanism of injuryAdmitting Hospital Unit (%)

MOI 23-Hr Observation Inpatient Unit Discharged (%) No. of Patients

Fall (general) 128 (62) 44 (21) 35 (17) 207Fall from shopping cart 15 (65) 2 (9) 6 (26) 23Dropped by caregiver 12 (63) 5 (26) 2 (11) 19MVA 4 (57) 2 (29) 1 (14) 7Pedestrian vs auto 3 (38) 4 (50) 1 (12) 8Bicycle vs auto 4 (67) 2 (33) None 6Sports-related 4 (57) 2 (29) 1 (14) 7ATV-related None None 3 (100) 3Object to the head 9 (56) 6 (38) 1 (6) 16Unknown history/possible NAT 5 (17) 20 (69) 4 (14) 29Kicked by horse None None 1 (100) 1Totals 184 (56) 87 (27) 55 (17) 326

ATV = all-terrain vehicle; auto = automobile; MVA = motor vehicle accident; NAT = nonaccidental trauma.

table 5. Fracture locationAdmitting Hospital Unit (%)

Fracture Location 23-Hr Observation Inpatient Unit Discharged (%) Total No. of Patients

Frontal bone 29 (66) 6 (14) 9 (20) 44 Frontal bone fracture involving orbital rim 9 (64) 3 (21) 2 (14) 14 Parietal bone 53 (52) 30 (29) 19 (19) 102 Temporal bone 13 (57) 7 (30) 3 (13) 23 Occipital bone 70 (56) 35 (28) 21 (17) 126 Single fracture involving 2 bones 10 (59) 6 (35) 1 (6) 17 Totals 184 (56) 87 (27) 55 (17) 326


e. n. arrey et al.


necessary. As demonstrated in this study and previously published reports, the likelihood of missing a delayed hemorrhage or other life-threatening complication in pa-tients with isolated NDSFs is extremely low.7,9,14 Based upon the findings in this review, we plan to attempt to find ways to minimize hospital transfers and admissions for isolated NDSFs, and we hypothesize that doing so would be worthwhile at other centers as well.

acknowledgmentThe participation of Eliel N. Arrey, BS, in this project was sup-

ported by the University of Texas Health-Science Center Summer Research Program Grant. This grant is funded by the National Institute of Neurological Diseases and Stroke (NIH Award no. 5 T35 NS 64931-5)

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9. Livingston DH, Lavery RF, Passannante MR, Skurnick JH, Baker S, Fabian TC, et al: Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. Ann Surg 232:126–132, 2000

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11. Moran C: Council OKs $13-a-mile ambulance charge. Hous-ton Chronicle. May 2, 2012. (http://www.chron.com/news/houston-texas/article/Council-OKs-13-a-mile-ambulance-charge-3530058.php) [Accessed June 23, 2015]

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14. Rollins MD, Barnhart DC, Greenberg RA, Scaife ER, Holsti M, Meyers RL, et al: Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg 46:1342–1346, 2011

15. Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG: Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr 19:258–264, 2007

16. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA: Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 118:483–492, 2006

17. Schutzman SA, Barnes P, Duhaime AC, Greenes D, Homer C, Jaffe D, et al: Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 107:983–993, 2001

18. Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, et al: The clinical utility of computed tomograph-ic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 33:385–394, 1992

19. Thiessen ML, Woolridge DP: Pediatric minor closed head injury. Pediatr Clin North Am 53:1–26, v, 2006

20. Yeates KO, Kaizar E, Rusin J, Bangert B, Dietrich A, Nuss K, et al: Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med 166:615–622, 2012

21. Yeates KO, Taylor HG, Rusin J, Bangert B, Dietrich A, Nuss K, et al: Longitudinal trajectories of postconcussive symp-toms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics 123:735–743, 2009

disclosureThe authors report no conflict of interest concerning the materi-als or methods used in this study or the findings specified in this paper.

author contributionsConception and design: Sandberg, Arrey, Kerr. Acquisition of data: Arrey, Kerr. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: Sandberg, Kerr, Fletcher, Cox. Reviewed submitted version of manuscript: all authors. Statistical analysis: Arrey. Administra-tive/technical/material support: Kerr. Study supervision: Sand-berg, Kerr, Fletcher, Cox.

correspondenceDavid I. Sandberg, Department of Pediatric Neurosurgery, Uni-versity of Texas Health Center at Houston, 6431 Fannin St., MSB 5.144, Houston, TX 77030. email: [email protected].


linear nondisplaced skull fractures in children: who should be … · traumatic brain injuries...

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