Clinical Assessment and Emergency Management of Pediatric Skull Fractures
Abstract
Background: Pediatric skull fractures are a common consequence of head trauma, with a high incidence in emergency settings. The unique anatomical and biomechanical properties of the developing skull, such as its thinness and pliability, influence fracture patterns and increase the risk of associated intracranial injury. Etiologies range from accidental falls to non-accidental trauma, necessitating a high index of suspicion in young children.
Aim: This review aims to detail the clinical assessment, diagnostic evaluation, and emergency management principles for pediatric skull fractures, emphasizing a systematic, evidence-based approach and the critical role of multidisciplinary care.
Methods: A comprehensive synthesis of current literature and clinical guidelines is presented, covering epidemiology, pathophysiology, and standardized evaluation protocols. The use of clinical decision rules (e.g., PECARN) to guide imaging, primarily non-contrast head CT, is discussed. Management strategies from initial Advanced Trauma Life Support (ATLS) stabilization to definitive neurosurgical intervention are outlined.
Results: Most simple, linear skull fractures can be managed conservatively with observation. Neurosurgical intervention is indicated for depressed fractures (>5 mm), open fractures, fractures with dural violation (CSF leak), associated intracranial hematomas, and growing skull fractures. A thorough evaluation must always consider the possibility of abusive head trauma, especially in infants.
Conclusion: Successful management of pediatric skull fractures requires rapid primary assessment, judicious use of imaging guided by clinical decision rules, and a tailored approach to intervention based on fracture type and associated injuries. Outcomes are optimized through coordinated, interprofessional teamwork involving emergency medicine, neurosurgery, pediatrics, and child protection services.
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References
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. 2006 Aug:118(2):483-92
Tunik MG, Powell EC, Mahajan P, Schunk JE, Jacobs E, Miskin M, Zuspan SJ, Wootton-Gorges S, Atabaki SM, Hoyle JD Jr, Holmes JF Jr, Dayan PS, Kuppermann N, Pediatric Emergency Care Applied Research Network (PECARN). Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma. Annals of emergency medicine. 2016 Oct:68(4):431-440.e1. doi: 10.1016/j.annemergmed.2016.04.058.
Bonfield CM, Naran S, Adetayo OA, Pollack IF, Losee JE. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. Journal of neurosurgery. Pediatrics. 2014 Aug:14(2):205-11. doi: 10.3171/2014.5.PEDS13414.
Karepov Y, Kozyrev DA, Benifla M, Shapira V, Constantini S, Roth J. E-bike-related cranial injuries in pediatric population. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2019 Aug:35(8):1393-1396. doi: 10.1007/s00381-019-04146-8.
Harsh V, Vohra V, Kumar P, Kumar J, Sahay CB, Kumar A. Elevated Skull Fractures - Too Rare to Care for, Yet too Common to Ignore. Asian journal of neurosurgery. 2019 Jan-Mar:14(1):237-239. doi: 10.4103/ajns.AJNS_242_17.
Campobasso CP, De Micco F, Bugelli V, Cavezza A, Rodriguez WC 3rd, Della Pietra B. Undetected traumatic diastasis of cranial sutures: a case of child abuse. Forensic science international. 2019 May:298():307-311. doi: 10.1016/j.forsciint.2019.03.011.
Krishnaprasadh D, Joyce T, Huecker MR. Pediatric Abusive Head Trauma. StatPearls. 2025 Jan:():
Mann KS, Chan KH, Yue CP. Skull fractures in children: their assessment in relation to developmental skull changes and acute intracranial hematomas. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 1986:2(5):258-61
Nelson EL, Melton LJ 3rd, Annegers JF, Laws ER, Offord KP. Incidence of skull fractures in Olmsted County, Minnesota. Neurosurgery. 1984 Sep:15(3):318-24
Donaldson K, Li X, Sartorelli KH, Weimersheimer P, Durham SR. Management of Isolated Skull Fractures in Pediatric Patients: A Systematic Review. Pediatric emergency care. 2019 Apr:35(4):301-308. doi: 10.1097/PEC.0000000000001814.
Hirst JN, Phung BR, Johnsson BT, He J, Coats B, Spear AD. Predicting fall parameters from infant skull fractures using machine learning. Biomechanics and modeling in mechanobiology. 2025 Apr:24(2):521-537. doi: 10.1007/s10237-024-01922-7.
Ryan ML, Thorson CM, Otero CA, Ogilvie MP, Cheung MC, Saigal GM, Thaller SR. Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department. The Journal of craniofacial surgery. 2011 Jul:22(4):1183-9. doi: 10.1097/SCS.0b013e31821c0d52.
Mannix R, Monuteaux MC, Schutzman SA, Meehan WP 3rd, Nigrovic LE, Neuman MI. Isolated skull fractures: trends in management in US pediatric emergency departments. Annals of emergency medicine. 2013 Oct:62(4):327-31. doi: 10.1016/j.annemergmed.2013.02.027.
Maguire S. Which injuries may indicate child abuse? Archives of disease in childhood. Education and practice edition. 2010 Dec:95(6):170-7. doi: 10.1136/adc.2009.170431.
Erşahin Y, Mutluer S, Mirzai H, Palali I. Pediatric depressed skull fractures: analysis of 530 cases. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 1996 Jun:12(6):323-31
Shane SA, Fuchs SM. Skull fractures in infants and predictors of associated intracranial injury. Pediatric emergency care. 1997 Jun:13(3):198-203
van den Heever CM, van der Merwe DJ. Management of depressed skull fractures. Selective conservative management of nonmissile injuries. Journal of neurosurgery. 1989 Aug:71(2):186-90
Braakman R. Depressed skull fracture: data, treatment, and follow-up in 225 consecutive cases. Journal of neurology, neurosurgery, and psychiatry. 1972 Jun:35(3):395-402
Saadat S, Rashidi-Ranjbar N, Rasouli MR, Rahimi-Movaghar V. Pattern of skull fracture in Iran: report of the Iran National Trauma Project. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES. 2011 Mar:17(2):149-51
Steinbok P, Flodmark O, Martens D, Germann ET. Management of simple depressed skull fractures in children. Journal of neurosurgery. 1987 Apr:66(4):506-10
Rollins MD, Barnhart DC, Greenberg RA, Scaife ER, Holsti M, Meyers RL, Mundorff MB, Metzger RR. Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. Journal of pediatric surgery. 2011 Jul:46(7):1342-6. doi: 10.1016/j.jpedsurg.2010.12.019.
Greenes DS, Schutzman SA. Infants with isolated skull fracture: what are their clinical characteristics, and do they require hospitalization? Annals of emergency medicine. 1997 Sep:30(3):253-9
Holsti M, Kadish HA, Sill BL, Firth SD, Nelson DS. Pediatric closed head injuries treated in an observation unit. Pediatric emergency care. 2005 Oct:21(10):639-44
Poorman GW, Segreto FA, Beaubrun BM, Jalai CM, Horn SR, Bortz CA, Diebo BG, Vira S, Bono OJ, DE LA Garza-Ramos R, Moon JY, Wang C, Hirsch BP, Tishelman JC, Zhou PL, Gerling M, Passias PG. Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database. International journal of spine surgery. 2019 Jan:13(1):68-78. doi: 10.14444/6009.
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger J, Surgical Management of Traumatic Brain Injury Author Group. Surgical management of depressed cranial fractures. Neurosurgery. 2006 Mar:58(3 Suppl):S56-60; discussion Si-iv
McAvoy M, Hopper RA, Lee A, Ellenbogen RG, Susarla SM. Pediatric Cranial Vault and Skull Base Fractures. Oral and maxillofacial surgery clinics of North America. 2023 Nov:35(4):597-606. doi: 10.1016/j.coms.2023.04.008.
Prasad GL, Gupta DK, Mahapatra AK, Borkar SA, Sharma BS. Surgical results of growing skull fractures in children: a single centre study of 43 cases. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2015 Feb:31(2):269-77. doi: 10.1007/s00381-014-2529-x.
Tandon PN, Banerji AK, Bhatia R, Goulatia RK. Cranio-cerebral erosion (growing fracture of the skull in children). Part II. Clinical and radiological observations. Acta neurochirurgica. 1987:88(1-2):1-9
Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid leakage. World journal of surgery. 2001 Aug:25(8):1062
Mendizabal GR, Moreno BC, Flores CC. Cerebrospinal fluid fistula: frequency in head injuries. Revue de laryngologie - otologie - rhinologie. 1992:113(5):423-5
Narang SK, Haney S, Duhaime AC, Martin J, Binenbaum G, de Alba Campomanes AG, Barth R, Bertocci G, Care M, McGuone D, COUNCIL ON CHILD ABUSE AND NEGLECT, SECTION ON OPHTHALMOLOGY, SECTION ON RADIOLOGY, SECTION ON NEUROLOGICAL SURGERY, SOCIETY FOR PEDIATRIC RADIOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS, AMERICAN ACADEMY OF OPHTHALMOLOGY. Abusive Head Trauma in Infants and Children: Technical Report. Pediatrics. 2025 Mar 1:155(3):. pii: e2024070457. doi: 10.1542/peds.2024-070457.
Galvagno SM Jr, Nahmias JT, Young DA. Advanced Trauma Life Support(®) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiology clinics. 2019 Mar:37(1):13-32. doi: 10.1016/j.anclin.2018.09.009.
Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015 May:135(5):e1337-54. doi: 10.1542/peds.2015-0356.
Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. International forum of allergy & rhinology. 2016 Jan:6(1):8-16. doi: 10.1002/alr.21637.
Hung KL. Pediatric abusive head trauma. Biomedical journal. 2020 Jun:43(3):240-250. doi: 10.1016/j.bj.2020.03.008.
Osmond MH, Klassen TP, Wells GA, Davidson J, Correll R, Boutis K, Joubert G, Gouin S, Khangura S, Turner T, Belanger F, Silver N, Taylor B, Curran J, Stiell IG, Pediatric Emergency Research Canada (PERC) Head Injury Study Group. Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2018 Jul 9:190(27):E816-E822. doi: 10.1503/cmaj.170406.
Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K, Children's head injury algorithm for the prediction of important clinical events study group. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Archives of disease in childhood. 2006 Nov:91(11):885-91
Schutzman SA, Barnes P, Duhaime AC, Greenes D, Homer C, Jaffe D, Lewis RJ, Luerssen TG, Schunk J. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics. 2001 May:107(5):983-93
Kim YI, Cheong JW, Yoon SH. Clinical comparison of the predictive value of the simple skull x-ray and 3 dimensional computed tomography for skull fractures of children. Journal of Korean Neurosurgical Society. 2012 Dec:52(6):528-33. doi: 10.3340/jkns.2012.52.6.528.
Mulroy MH, Loyd AM, Frush DP, Verla TG, Myers BS, Bass CR. Evaluation of pediatric skull fracture imaging techniques. Forensic science international. 2012 Jan 10:214(1-3):167-72. doi: 10.1016/j.forsciint.2011.07.050.
Shogan H, Bhangu AK. Detection of paediatric skull fractures using POCUS. Emergency medicine journal : EMJ. 2025 Feb 21:42(3):209-210. doi: 10.1136/emermed-2024-214540.
Grechenig W, Clement HG, Fellinger M, Seggl W. Scope and limitations of ultrasonography in the documentation of fractures--an experimental study. Archives of orthopaedic and trauma surgery. 1998:117(6-7):368-71
Wu H, Zhong YM, Nie QM, Chen WB, Guo LM, Yang X, Zhang H, Lin Y, Xu JR, Dai YM, Zhu M. Feasibility of three-dimensional ultrashort echo time magnetic resonance imaging at 1.5 T for the diagnosis of skull fractures. European radiology. 2016 Jan:26(1):138-46. doi: 10.1007/s00330-015-3804-2.
Bradford R, Choudhary AK, Dias MS. Serial neuroimaging in infants with abusive head trauma: timing abusive injuries. Journal of neurosurgery. Pediatrics. 2013 Aug:12(2):110-9. doi: 10.3171/2013.4.PEDS12596.
Kleinman PK, Nimkin K, Spevak MR, Rayder SM, Madansky DL, Shelton YA, Patterson MM. Follow-up skeletal surveys in suspected child abuse. AJR. American journal of roentgenology. 1996 Oct:167(4):893-6
Zimmerman S, Makoroff K, Care M, Thomas A, Shapiro R. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child abuse & neglect. 2005 Oct:29(10):1075-83
Bennett BL, Chua MS, Care M, Kachelmeyer A, Mahabee-Gittens M. Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC research notes. 2011 Sep 12:4():354. doi: 10.1186/1756-0500-4-354.
Borgialli DA, Mahajan P, Hoyle JD Jr, Powell EC, Nadel FM, Tunik MG, Foerster A, Dong L, Miskin M, Dayan PS, Holmes JF, Kuppermann N, Pediatric Emergency Care Applied Research Network (PECARN). Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2016 Aug:23(8):878-84. doi: 10.1111/acem.13014.
Jain S, Margetis K, Iverson LM. Glasgow Coma Scale. StatPearls. 2025 Jan
Beaudin M, Saint-Vil D, Ouimet A, Mercier C, Crevier L. Clinical algorithm and resource use in the management of children with minor head trauma. Journal of pediatric surgery. 2007 May:42(5):849-52
Kadish HA, Schunk JE. Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization? Annals of emergency medicine. 1995 Jul:26(1):37-41
Marentette LJ, Valentino J. Traumatic anterior fossa cerebrospinal fluid fistulae and craniofacial considerations. Otolaryngologic clinics of North America. 1991 Feb:24(1):151-63
Gupta SK, Reddy NM, Khosla VK, Mathuriya SN, Shama BS, Pathak A, Tewari MK, Kak VK. Growing skull fractures: a clinical study of 41 patients. Acta neurochirurgica. 1997:139(10):928-32
Liu XS, You C, Lu M, Liu JG. Growing skull fracture stages and treatment strategy. Journal of neurosurgery. Pediatrics. 2012 Jun:9(6):670-5. doi: 10.3171/2012.2.PEDS11538.
Schutzman SA, Greenes DS. Pediatric minor head trauma. Annals of emergency medicine. 2001 Jan:37(1):65-74
Hoehn EF, Wilson PM, Riney LC, Ngo V, Bennett B, Duma E. Identification and Evaluation of Physical Abuse in Children. Pediatric annals. 2018 Mar 1:47(3):e97-e101. doi: 10.3928/19382359-20180227-01.
Riney LC, Frey TM, Fain ET, Duma EM, Bennett BL, Murtagh Kurowski E. Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department. Pediatrics. 2018 Jan:141(1):. pii: e20171994. doi: 10.1542/peds.2017-1994.
Van Saun RJ. Trace Mineral Metabolism: The Maternal-Fetal Bond. The Veterinary clinics of North America. Food animal practice. 2023 Nov:39(3):399-412. doi: 10.1016/j.cvfa.2023.06.003.
Talari HR, Hamidian Y, Moussavi N, Fakharian E, Abedzadeh-Kalahroudi M, Akbari H, Taher EB. The Prognostic Value of Rotterdam Computed Tomography Score in Predicting Early Outcomes Among Children with Traumatic Brain Injury. World neurosurgery. 2019 May:125():e139-e145. doi: 10.1016/j.wneu.2018.12.221.
Orru' E, Huisman TAGM, Izbudak I. Prevalence, Patterns, and Clinical Relevance of Hypoxic-Ischemic Injuries in Children Exposed to Abusive Head Trauma. Journal of neuroimaging : official journal of the American Society of Neuroimaging. 2018 Nov:28(6):608-614. doi: 10.1111/jon.12555.
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Copyright (c) 2025 Abdulrahman Mohammed Abdulrahman Almazyad, Eisa Ali T. Alenazi, Sultan Mukhlid Nazil Al-Anazi, Faisal Jazzaa Muhammad Al-Anazi, Faleh Eid Faleh Alruwaili, Abdulrhman Mouhsen Ali Al-Shammari, Farih Bustan Alruwaili, Zaid Ayash Madhi Alruwaili, Abdulelah Saad Alsaleem, Abdulraman Jawad Jawdat Rasheed, Talal Ali Alsharari, Aqla Mottleb Hamoud Alhazm, Ayed Al Asmar Ogl Alsuwaylimi , Fahhad Nadi Shukhayr Alhazmi, Bader Ahmed Thamer Almsud
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