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BACKGROUND:
Pediatric skull fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts and affect brain and craniofacial development. The aim of this study was to characterize demographics, injury patterns, associated injuries, and treatment for this patient population.
METHODS:
A retrospective review of patients <18 years of age presenting since 2000 with skull fractures was performed. Patients were included regardless of treating specialty, treatment modality, or inpatient status. Demographics, mechanism of injury, associated injuries, fracture patterns, surgical intervention, complications, and outcomes were analyzed. Groups treated non-operatively, operatively for skull fracture repair, and for traumatic brain injury were compared.
RESULTS:
923 patients met our inclusion criteria, the majority of which (63.6%) were male (p<0.01). 82.4% were admitted, of which 27.1% required ICU care. Average age at injury was 5.97±13.35 years. 19.2% had associated facial fractures, and 23.4% had other severe associated injuries. 150 patients required interventions: 42% for traumatic brain injury (TBI), 41.3% for skull fractures (Operative Repair), and 16.7% for associated facial injuries. The Non-Operative group was significantly younger, while the TBI group had a lower initial Glasgow Coma Scale (GCS). Frontal bone fracture was seen most in the Operative Repair and TBI groups, with parietal bone the most frequent bone fractured in the Non-Operative group. The TBI group was more likely to have 2 or 3 skull bones fractured. In the Operative Repair group, 36.2% had a complication (38.0% intervention related, 62.0% trauma related), but no patient had a worsening of their neurologic status. Late sequelae including post-craniotomy contour and soft tissue deformities, growing skull fracture, seizures, headaches, learning disability, and wound healing complications were observed. In the TBI group, 48.7% suffered a complication, primarily (90.6%) related to the trauma. There was one mortality. Male subjects, victims of falls, and patients with direct trauma to the head were significantly more likely to sustain skull fractures (p≤0.01). 19.6 percent of children with fractures as a result of a violent mechanism were from a highly impoverished ZIP code, as compared to the 8% of those not involved in violent injuries.
CONCLUSIONS:
For pediatric patients presenting with a skull fracture, injury patterns are significantly correlated with gender and mechanism of injury. The majority may be managed conservatively. Of those requiring surgical intervention, less than half are performed on the basis of skull fracture repair only. Patients hit in the head with an object or involved in an MVC are more likely to need surgical intervention either to repair the skull fracture or for TBI management, respectively. Frontal bone fractures are more likely to necessitate repair, and those patients treated for TBI have a greater incidence of 2 or 3 bones involved in the fracture. Most complications were related to underlying trauma. Violent mechanisms of trauma were associated with impoverished communities. Management requires a multidisciplinary approach. A better understanding of this fracture population will enable practitioners to better identify patients at risk, injury patterns, and late sequelae of pediatric skull fractures.