HWN Suggests

Bursting at the Skull: Skull Fractures

Various clinical features may warrant a head CT. While gestalt can serve as a valuable guide among advanced clinicians, multiple clinical decision rules (CDR) can aid in the decision as to the necessity for a Head CT, including Nexus II, New Orleans Criteria, or the Canadian CT rule. The Canadian CT Rule appears to be the most sensitive CDR to evaluate for clinically significant intracranial pathology. In one study sensitivity for need of neurosurgical intervention using the Canadian CT rule was 100% (95% CI 90-100%) with 60% specificity. Many other validation studies have proven superiority of the Canadian CT Rule over that of Nexus II and the New Orleans Criteria. ACEP has a clinical guidelines…

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  Canadian CT Head Injury/Trauma Rule

Only apply to patients with Glasgow Coma Scale (GCS) 13-15 and at least one of the following: Loss of consciousness. Amnesia to the head injury event. Witnessed disorientation. While there is only one US validation study for the CCHR, it was 100% sensitive for clinically important injuries and injuries requiring neurosurgery.

 Head Injury: minor, minimal or trivial. The difference matters!

The Canadian CT Head rule is a great rule. Really. Yet, time and time again we see it applied erroneously, or learners fail to appreciate the population for whom this decision rule was meant. Patients with head injury are often seriously over investigated, and this likely is secondary to a lack of appreciation regarding decision making. Here, we seek to dissect some of the nuances.

 The Canadian CT Head Rule for Patients with Minor Head Injuries

As part of the CanadiEM MVP Infographic Series, this post reviews The Canadian CT Head Rule for Patients with Minor Head Injuries​1. This article developed a highly sensitive algorithm to aid clinicians in deciding whether patients presenting with minor head injuries should undergo a CT scan. Prior to this study, recommendations for imaging a minor head injury conflicted. This made it difficult for physicians to determine which patients were at higher risk for developing intracranial hematoma. Therefore, patients were extensively over-imaged, as only 0.7-3.7% of patients were found to have intracranial pathology on CT scans. Consequently, many patients were being exposed to unnecessary radiation, and healthcare resources were over-utilized to fund the scans.

Articles of Interest

A Review of Basilar Skull Fractures

All patients with basilar skull fractures should be admitted for observation. Management is based on anticipated complications. Most post-traumatic CSF leaks heal with a conservative management of bed rest and head elevation.

Base of Skull Fracture

Persistent leaks >7 days have heightened risk of meningitis and are often surgically repaired

Diagnostic and Clinical Management of Skull Fractures in Children

Our findings support previous evidence against the routine use of skull X-rays for evaluation of children with minor head injury. The rate of diagnosed skull fractures in radiographs following minor head trauma is low, and additional CT scans are not indicated in asymptomatic patient with a linear skull fracture.

Interpreting Skull Fractures and Their Causes

This blog post focuses on a related topic: skull fractures. This broad term represents an extensive list of 20 specific types of fracture, each with its own etiology (cause) and description. Most fractures can indicate a fall, motor vehicle collision, or other impact to the skull, but some connote assault. Determining the potential cause of a skull fracture can be an important factor in your case. Use the following list to help sort the complexities of skull fracture.

Isolated skull fractures in pediatrics

Pediatric patients with an isolated skull fracture and normal neurological exam have a low risk of neurosurgical intervention and outpatient follow up may be appropriate (assuming no suspicion of abuse and a reliable family).

Linear Skull Fracture Pediatrics

Skull fracture is the most common traumatic finding in kids with abnormal imaging after head injury. Younger children (< 2 years of age, especially infants < 1 year of age) are particularly at risk for skull fracture. Majority of skull fractures can be managed conservatively.

Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review

Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking.

When to Use Point-of-Care Ultrasound for Skull Fractures

Several authors have investigated using POCUS for diagnosing pediatric skull fractures. The sensitivities from these studies range from 82 percent to 100 percent and specificity from 94 percent to 100 percent.

Resources

DDxof.com

Types of Skull Fractures...

Radiopaedia

Skull fractures are best imaged with CT of the brain. Not only is CT sensitive to the detection fractures but it is also able to exquisitely characterize their extent and allow for surgical planning. Furthermore, it is obtained at the same time as the brain is imaged.