Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

Maxwell Gruber Department of Pediatric Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio; and

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Nate Klingele Department of Neurosurgery, Ohio State University, Columbus, Ohio

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Christy Monson Department of Pediatric Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio; and

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Eric A. Sribnick Department of Pediatric Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio; and

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BACKGROUND

After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home.

OBSERVATIONS

Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection.

LESSONS

In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

ABBREVIATIONS

CT = computed tomography; MRI = magnetic resonance imaging; TBI = traumatic brain injury

BACKGROUND

After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home.

OBSERVATIONS

Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection.

LESSONS

In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

ABBREVIATIONS

CT = computed tomography; MRI = magnetic resonance imaging; TBI = traumatic brain injury

Traumatic brain injury (TBI) in children is a common occurrence; however, the majority of these injuries are mild and do not result in long-term morbidity or operative intervention.1 Clinicians attempt to avoid unnecessary imaging, and this is especially true concerning modalities in children as ionizing radiation exposure is associated with an increased lifetime risk of cancer.2 Excellent clinical tools have been developed to risk-stratify pediatric patients with TBI to try and avoid unnecessary head computed tomography (CT) following blunt injury.3 Cranial injuries involving a thin object (e.g., pencil, rod, or nail) can present with a well-appearing patient, an unimpressive puncture site, and an underlying open, depressed skull fracture.4 If unrecognized and not treated within 48 hours, an open, depressed skull fracture with contamination can result in infection.5 We report on the case of a child who experienced a puncture wound with unrecognized open, depressed skull fracture with intracranial contamination. We discuss evaluation, management, and strategies to avoid missing this type of injury.

Illustrative Case

A 10-year-old, otherwise healthy male presented to an outpatient urgent care clinic following impaction of the scalp by a chained survey flag while playing with his brother. The patient was evaluated by a board-certified emergency medicine physician. The patient’s history denoted no instance of emesis, headache, or loss of consciousness after the incident or at the time of evaluation. Neurological examination revealed no evidence of deficit, and the patient and his family denied any evidence of neurological complaints. Skull radiographs were obtained (Fig. 1) and read as showing an increased density within the left parietal bone with no evidence of traumatic injury. Assessment, at that time, was of a small scalp laceration. The laceration was irrigated with normal saline, and the scalp edges were reapproximated using absorbable suture. The patient was subsequently discharged home.

FIG. 1.
FIG. 1.

Skull radiographs from the anteroposterior (A) and lateral (B) positions were obtained on initial evaluation. These were read as showing increased density within the left parietal bone, but no traumatic injury was detected.

Two days later, the patient represented to the Emergency Department of our level 1 pediatric trauma center. At that time, he was notable for multiple complaints including subjective intermittent numbness and weakness of the right hemibody, emesis, and ataxic gait. Neurological exam revealed 4+/5 motor strength in the right upper and lower extremity and right-sided pronator drift. He had no evidence of fever or meningitis, and his white blood cell count was 8.1 K/mm3 (range 4.5–13.5).

Imaging at that time included head CT and brain magnetic resonance imaging (MRI). The CT scan demonstrated a focal, comminuted left parietal bone fracture measuring 8 mm in diameter (Fig. 2A). Comminuted fragments of skull were noted to be rotated and displaced into the cranial vault by up to 11 mm (Fig. 2B). The MRI was notable for similar findings of skull fracture fragments displaced into the brain parenchyma but also demonstrated that bone fragments were 8 mm lateral to the midline superior sagittal sinus and 4 mm anterior to the left vein of Trolard (Fig. 2C). Additionally, MRI highlighted an approximate 2-cm3 hemorrhagic brain contusion and surrounding edema (Fig. 2D).

FIG. 2.
FIG. 2.

Two days following the initial presentation, further imaging included head CT (A and B) and brain MRI (C and D). The three-dimensional reconstruction of the head CT (A) demonstrated a focal punctate fracture to the left parietal bone. In the coronal plane (B), the rotated and depressed fragments of bone were visualized. Brain MRI using T2 inversion recovery in the axial plane (C) demonstrated the hypointense fracture fragments extending into the brain parenchyma, and these were less than 1 cm from the superior sagittal sinus (red arrowheads) and the vein of Trolard (white arrowheads). Susceptibility weighted imaging (D) demonstrated the resultant left parietal brain contusion.

Given these findings, neurosurgical consultation was made and the patient was started on empirical antibiotic therapy (intravenous vancomycin, cefepime, and metronidazole). He was taken urgently for left parietal craniotomy for wound debridement and elevation of fracture fragments. Given the proximity of the fracture to surrounding vasculature, a high-speed drill was used to remove enough bone from the anterior fragment to allow it to be removed. The remaining 3 fracture fragments were gently elevated and removed. The fracture site itself was grossly contaminated with devitalized scalp, bone fragments, hair, and extruded brain. Following debridement, the site was gently irrigated with 3 L of normal saline. The cranial defect was covered using a titanium burr hole cover plate affixed to the bone using titanium screws.

Multiple cultures were obtained from the fracture site, including aerobic, anaerobic, fungal, and acid-fast bacilli. Additionally, a bone fracture fragment was sent for tissue culture and blood cultures were obtained prior to starting antibiotics or operative intervention. Return cultures demonstrated no growth. The infectious disease team was consulted, and antibiotic therapy was continued with oral metronidazole and intravenous ceftriaxone for 2 weeks.

All antibiotics were discontinued after 2 weeks. There was no evidence of local or systemic infection noted thereafter. Brain MRI was performed when antibiotics were discontinued and demonstrated postoperative changes with no evidence of abscess formation. Subsequent imaging at 6 weeks follow-up exhibited cystic encephalomalacia at the injury site with no evidence of infection.

Neurologically, his immediate postoperative exam demonstrated weakness unchanged from his preoperative exam. He was started on physical and occupational therapy, and his strength was grossly normal by 1 month following surgery. Occupational therapy was discontinued 1 month after injury, and physical therapy was discontinued 3 months after injury. He was last evaluated in the neurosurgery clinic approximately 12 months postoperatively, and the patient was noted to have no residual sequelae and was doing well academically and in his extracurricular activities.

Discussion

Observations

This case highlights a rarely seen injury pattern involving a thin rod-like projectile impacting the skull at a relatively low velocity. In such cases, the projectile can create a punctate skull fracture with little overlying disruption to the scalp, making the superficial wound appear potentially unremarkable. If non-eloquent brain is involved in the injury, there may be little neurological sequelae initially. In this presented case, the injury extended posteriorly to the precentral gyrus (primary motor cortex), and despite the location of the injury over eloquent cortex, the patient was reportedly asymptomatic until 2 days following the event.

The physics of a rod-like object striking the cranium with the “nose” of the projectile allows for energy transfer to a small surface area, greatly increasing the pressure at the site of impact.6 This may explain how a relatively inconspicuous object can create significant damage despite evidence of only a small laceration over the fracture site. Other examples of similar missed skull injuries have been reported, and the parietal and temporal bones appear to be most susceptible to these types of injuries.4,7

The development of guidelines for the utilization of head CT for the evaluation of TBI is important and has likely reduced the number of tests ordered.8 Nonetheless, limitations of these studies should be recognized when used clinically. For instance, one of the more robust studies to produce head CT guidelines excluded patients with “trivial injury mechanisms,” evidence of penetrating trauma, known brain tumor, a neurological condition that would complicate assessment, or for patients with concerns for abusive head trauma.3,9

In cases where there is ambiguity of whether head CT is necessary, skull radiograph may appear to be a reasonable alternative as it delivers a lower dose of ionizing radiation.10,11 However, as shown in this presented case and in multiple prior studies, injuries to the skull can be missed on skull X-ray.12,13 In this case, a significant, clinically relevant skull injury with accompanying traumatic brain injury was missed. More concerning, the injury represented direct contamination of the central nervous system with risk of infection if not recognized and treated. More recently, rapid-sequence MRI of the brain has been considered for initial evaluation of TBI. This modality delivers no radiation and appears to be sensitive to all but linear skull fractures and small hemorrhages.14

Lessons

Fortunately, in this presented case, delayed neurological sequelae of the injury prompted re-evaluation, but the potential lesson learned is that a long, thin projectile (in this case, something as innocuous as a surveyor marking flag) can transmit surprising pressure on impact and should warrant evaluation for both blunt and penetrating injury. Despite a full physical exam, only a superficial wound was noted, but a CT scan revealed that clearly there was a greater energy transfer than suggested by the initial inspection. Additionally, while radiography is a convenient and reliable imaging modality for visualizing gross fractures, small circumferential fractures such as this may be missed due to patient movement or the presence of the fracture within the plane of image acquisition.

Disclosures

Dr. Sribnick reported grants from National Institutes of Health outside the submitted work. No other disclosures were reported.

Author Contributions

Conception and design: Klingele, Monson, Sribnick. Acquisition of data: Monson, Sribnick. Analysis and interpretation of data: Klingele, Monson, Sribnick. Drafting of the article: Gruber, Klingele, Sribnick. Critically revising the article: Sribnick. Reviewed submitted version of the manuscript: Monson, Sribnick Study Supervision: Sribnick.

References

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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700707.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):11601170.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Maruca-Sullivan PE, Goldenberg MN, Cone DC, Ciarleglio J. Missing the point: self-inflicted traumatic brain injury in psychosis. BMJ Case Rep. 2016;2016:bcr2016216767.

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  • 5

    Jennett B, Miller JD. Infection after depressed fracture of skull. Implications for management of nonmissile injuries. J Neurosurg. 1972;36(3):333339.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Fowler D. Biomechanics of injury. In: Troncoso J, Fowler D, Rubio A, eds. Essential Forensic Neuropathology. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

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  • 7

    Tavor O, Boddu S, Glatstein M, Lamberti M, Kulkarni AV, Scolnik D. The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention. Childs Nerv Syst. 2020;36(12):30213025.

    • PubMed
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  • 8

    Niele N, van Houten M, Tromp E, van Goudoever JB, Plötz FB. Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries. Eur J Pediatr. 2020;179(10):15971602.

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  • 9

    Magana JN, Kuppermann N. The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med. 2017;24(3):382384.

  • 10

    Mazonakis M, Damilakis J, Raissaki M, Gourtsoyiannis N. Radiation dose and cancer risk to children undergoing skull radiography. Pediatr Radiol. 2004;34(8):624629.

    • PubMed
    • Search Google Scholar
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  • 11

    Sheppard JP, Nguyen T, Alkhalid Y, Beckett JS, Salamon N, Yang I. Risk of brain tumor induction from pediatric head CT procedures: a systematic literature review. Brain Tumor Res Treat. 2018;6(1):17.

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    • Search Google Scholar
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  • 12

    Chawla H, Malhotra R, Yadav RK, Griwan MS, Paliwal PK, Aggarwal AD. Diagnostic utility of conventional radiography in head injury. J Clin Diagn Res. 2015;9(6):TC13TC15.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Lloyd DA, Carty H, Patterson M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet. 1997;349(9055):821824.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kessler BA, Goh JL, Pajer HB, et al. Rapid-sequence MRI for evaluation of pediatric traumatic brain injury: a systematic review. J Neurosurg Pediatr. 2021;28(3):19.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1.

    Skull radiographs from the anteroposterior (A) and lateral (B) positions were obtained on initial evaluation. These were read as showing increased density within the left parietal bone, but no traumatic injury was detected.

  • FIG. 2.

    Two days following the initial presentation, further imaging included head CT (A and B) and brain MRI (C and D). The three-dimensional reconstruction of the head CT (A) demonstrated a focal punctate fracture to the left parietal bone. In the coronal plane (B), the rotated and depressed fragments of bone were visualized. Brain MRI using T2 inversion recovery in the axial plane (C) demonstrated the hypointense fracture fragments extending into the brain parenchyma, and these were less than 1 cm from the superior sagittal sinus (red arrowheads) and the vein of Trolard (white arrowheads). Susceptibility weighted imaging (D) demonstrated the resultant left parietal brain contusion.

  • 1

    Dewan MC, Mummareddy N, Wellons JC 3rd, Bonfield CM. Epidemiology of global pediatric traumatic brain injury: qualitative review. World Neurosurg. 2016;91:497509.e1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700707.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):11601170.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Maruca-Sullivan PE, Goldenberg MN, Cone DC, Ciarleglio J. Missing the point: self-inflicted traumatic brain injury in psychosis. BMJ Case Rep. 2016;2016:bcr2016216767.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Jennett B, Miller JD. Infection after depressed fracture of skull. Implications for management of nonmissile injuries. J Neurosurg. 1972;36(3):333339.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Fowler D. Biomechanics of injury. In: Troncoso J, Fowler D, Rubio A, eds. Essential Forensic Neuropathology. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Tavor O, Boddu S, Glatstein M, Lamberti M, Kulkarni AV, Scolnik D. The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention. Childs Nerv Syst. 2020;36(12):30213025.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Niele N, van Houten M, Tromp E, van Goudoever JB, Plötz FB. Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries. Eur J Pediatr. 2020;179(10):15971602.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Magana JN, Kuppermann N. The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med. 2017;24(3):382384.

  • 10

    Mazonakis M, Damilakis J, Raissaki M, Gourtsoyiannis N. Radiation dose and cancer risk to children undergoing skull radiography. Pediatr Radiol. 2004;34(8):624629.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Sheppard JP, Nguyen T, Alkhalid Y, Beckett JS, Salamon N, Yang I. Risk of brain tumor induction from pediatric head CT procedures: a systematic literature review. Brain Tumor Res Treat. 2018;6(1):17.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chawla H, Malhotra R, Yadav RK, Griwan MS, Paliwal PK, Aggarwal AD. Diagnostic utility of conventional radiography in head injury. J Clin Diagn Res. 2015;9(6):TC13TC15.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Lloyd DA, Carty H, Patterson M, Butcher CK, Roe D. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet. 1997;349(9055):821824.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kessler BA, Goh JL, Pajer HB, et al. Rapid-sequence MRI for evaluation of pediatric traumatic brain injury: a systematic review. J Neurosurg Pediatr. 2021;28(3):19.

    • PubMed
    • Search Google Scholar
    • Export Citation

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