Assessing the potential for abusive injury in preverbal children is a challenge. Because head trauma is a common occurrence in young children, clinicians often face a dilemma about whether to perform a more extensive evaluation for other evidence of injury when historical "red flags" for abuse are not present.
Methods. This study was a retrospective chart review of patients ≤ 18 months old who had isolated skull fractures when seen at a single pediatric referral center during a 7-year period ending December 31, 2010. For all children, the chief complaint was possible head injury without suspicion of significant intracranial injury. Children were identified from diagnostic codes, excluding those whose skull fractures were identified incidentally or were the result of birth trauma or a verifiable traumatic event such as a motor vehicle crash. Children with intracranial hemorrhage evident on imaging were also excluded, but children with minimal (localized) intracranial hemorrhage associated with the isolated skull fracture were included. The study accounted for demographic features, the type of skull fracture, and the presence of red flags suggestive of abuse, such as conflicting or changing history given by the caregivers, a delay in care (> 72 hours after injury), previous interaction with Child Protective Services, or evidence of other injuries identified on the physical examination. Falls were classified according to distance (≤ 3 feet or > 3 feet).
Findings. A protocol was followed by the emergency department at the referral center whereby most children with isolated skull fractures received skeletal surveys. Of 175 children who presented during the study period and met study criteria, 150 (86%) received a skeletal survey, and 35% of those children had at least 1 red flag in their history or physical examination. The mean age of the children was 5.2 months, and almost two thirds were less than 6 months old. The children were primarily white, with 14% black and 6% Hispanic. About two thirds were publicly insured.
Among children who had a skeletal survey, 9 (6%) had at least 1 additional fracture. Most of the associated fractures were rib, upper-, or lower-extremity fractures. Most skull fractures were simple skull fractures. An additional fracture was found on the skeletal surveys of 13% of children who had at least 1 red flag. The most common red flag was a delay in care, but caregivers being unable to give a history of the injury was also prevalent, as was a changing history.
Laskey and colleagues concluded that performing a skeletal survey on preverbal children with apparent isolated skull fractures identifies additional fractures in 6% of cases. They suggested that because 7 of the 9 cases with additional fractures were in children younger than 6 months old, it may also be reasonable to restrict skeletal surveys to those very young infants. Mobile toddlers who are more likely to demonstrate pain or impaired mobility from a fracture might be a group in which to consider avoiding skeletal surveys if they have a normal physical examination.