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Management of Isolated Skull Fractures in Pediatric Patients

A Systematic Review

Donaldson, Katelyn, BS*; Li, Xun, MD; Sartorelli, Kennith H., MD; Weimersheimer, Peter, MD, FACEP§; Durham, Susan R., MD, MS

doi: 10.1097/PEC.0000000000001814
Review Article

Objectives Isolated skull fractures (ISFs) in children are one of the most common emergency department injuries. Recent studies suggest these children may be safely discharged following ED evaluation with little risk of delayed neurological compromise. The aim of this study was to propose an evidence-based protocol for the management of ISF in children in an effort to reduce medically unnecessary hospital admissions.

Methods Using PubMed and The Cochrane Library databases, a literature search using the search terms (pediatric OR child) AND skull fracture AND (isolated OR linear) was performed. Three hundred forty-three abstracts were identified and screened based on the inclusion criteria: (1) linear, nondepressed ISF; (2) no evidence of intracranial injury; (3) age 18 years or younger; and (4) data on patient outcomes and management. Data including age, Glasgow Coma Scale score on arrival, repeat imaging, admission rates, need for neurosurgical intervention, and patient outcome were collected. Two authors reviewed each study for data extraction and quality assessment.

Results Fourteen articles met the eligibility criteria. Data including admission rates, outcomes, and necessity of neurosurgical intervention were analyzed. Admission rates ranged from 56.8% to 100%; however, only 8 of more than 5000 patients developed new imaging findings after admission, all of which were nonsurgical. Only 1 patient required neurosurgical intervention for a finding evident upon initial evaluation.

Conclusions Pediatric ISF patients with a presenting Glasgow Coma Scale score of 15 who are neurologically intact and tolerating feeds without concern for nonaccidental trauma or an unstable social environment can safely be discharged following ED evaluation to a responsible caregiver.

From the *University of Vermont College of Medicine, Burlington, VT;

Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI; and Divisions of

Pediatric Surgery,

§Emergency Medicine, and

Neurosurgery, University of Vermont College of Medicine, Burlington, VT.

Disclosure: The authors declare no conflict of interest.

Reprints: Susan R. Durham, MD, MS, Division of Neurosurgery, University of Vermont College of Medicine, 111 Colchester Ave, Burlington, VT 05401 (e-mail:

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