Editorial: Do skull fractures matter?

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The humble skull fracture is a bit of a Cinderella— viewed as largely irrelevant and not worthy of much attention by many traumatic brain injury (TBI) investigators, but often perceived as having great importance by primary care providers and, especially, by parents. The literature on pediatric skull fractures remains sparse, and so the article by Bonfield et al.1 provides some welcome information for pediatric neurosurgeons when teaching colleagues, writing chapters, or counseling families regarding this common occurrence.

The authors provide a retrospective, single-center series of 897 patients with skull fractures and analyze the patients by treatment groups—those treated

The humble skull fracture is a bit of a Cinderella— viewed as largely irrelevant and not worthy of much attention by many traumatic brain injury (TBI) investigators, but often perceived as having great importance by primary care providers and, especially, by parents. The literature on pediatric skull fractures remains sparse, and so the article by Bonfield et al.1 provides some welcome information for pediatric neurosurgeons when teaching colleagues, writing chapters, or counseling families regarding this common occurrence.

The authors provide a retrospective, single-center series of 897 patients with skull fractures and analyze the patients by treatment groups—those treated without surgery, those treated surgically specifically for the fracture, and those treated surgically for associated TBI.1 They report the distribution of fracture location, fracture mechanisms, patient age, and complications. While the report has the typical limitations of a retrospective study, including few data regarding rationale for specific management decisions, the authors provide a useful snapshot of an often under-described part of the injury complex. The analysis shows that trauma involving motor vehicles and being struck in the head by an object more often resulted in the need for surgery than did falls. While the parietal bone was the most common site of fracture overall, fractures requiring surgery more often involved the frontal bone or multiple bones, usually to treat open or depressed fractures. Not surprisingly, patients with skull fractures who underwent surgery primarily for their associated brain injuries often had hematomas and underwent hematoma evacuation, decompression, and/or external ventricular drainage.

Also of interest to surgeons is the finding that a significant number of complications involved hardware that required subsequent removal, and the authors noted an evolution in their practice from the use of permanent to absorbable hardware. Whether this will lead to fewer complications and is cost effective remains to be studied.

Several questions about skull fractures in the pediatric population remain unanswered. Pediatric neurosurgeons have joined with other specialties in attempting to reduce radiation exposure in young patients, but if substituting rapid MRI techniques in acute trauma assessment leads to missed linear skull fractures, is this important? This study would suggest that open and depressed fractures— those most likely to require surgery for the fracture alone—are likely to be obvious on clinical grounds and might be expected to be sufficiently characterized by most rapid MRI techniques. In the functional realm, are patients who sustain enough force to create a skull fracture at risk for similar “mild traumatic brain injury” signs and symptoms—and vulnerabilities to short- and longterm consequences—as those without skull fracture? In practical terms, should you treat a patient with a linear skull fracture with similar restrictions as you typically treat a patient with a “concussion,” even if there are few neurological symptoms? Alternatively, does the energy “absorbed” by the skull, resulting in fracture, somehow protect the brain? Does any of this vary with skull deformability, which varies with age? It will be for future studies, in which skull and brain injuries are prospectively characterized and correlated with functional outcome measures, to help determine whether fractures independently influence neurocognitive outcome, and whether patients with isolated skull fractures not requiring surgical intervention or associated with a significant brain injury should be managed in any particular way.

Disclosure

The author reports no conflict of interest.

Reference

1

Bonfield CMNaran SAdetayo OAPollack IFLosee JE: Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. Clinical article. J Neurosurg Pediatr [epub ahead of print June 6 2014. DOI: 10.3171/2014.5.PEDS13414]

Response

We would like to thank Dr. Duhaime for her insightful comments on our article. In this study, we reviewed our experience, at a busy pediatric regional trauma center, with a common problem that is often the reason for neurosurgical consultation by pediatricians and emergency department physicians, specifically skull fractures. Although the vast majority of children with skull fractures do not require surgical intervention, it is important to understand the characteristics, indications, and injury patterns of those patients who do. Of those requiring intervention, fewer than half of surgeries are performed solely for skull fracture elevation and repair. Patients hit in the head with an object or involved in a motor vehicle crash are more likely to need surgical intervention, either to repair the skull fracture or for underlying 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. Furthermore, the majority of complications are a direct result of the trauma, not the surgical intervention.

As noted by Dr. Duhaime, the literature on pediatric skull fractures remains sparse, and further studies, especially related to the functional outcome and sequelae, are necessary. As more investigation into concussion is undertaken, it remains to be determined whether conclusions regarding mild TBI would be applicable to children with uncomplicated skull fractures. How characteristics of the trauma, age of the patient, location of the fracture, and so on are related to the child's functional outcome should all be points of emphasis in future studies. Further evaluation of the types of hardware that are optimally used for repair is also an area that warrants exploration.

Despite these unanswered questions, we feel that this study begins to fill a gap in the pediatric brain trauma literature. Especially as goals of decreasing radiation and cost continue to be sought, the importance of refining the management of skull fractures is increasingly apparent. Also, these insights will be useful for educating nonneurosurgical colleagues and counseling families of affected patients.

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Article Information

Please include this information when citing this paper: published online June 6, 2014; DOI: 10.3171/2014.3.PEDS14104.

© AANS, except where prohibited by US copyright law.

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References

1

Bonfield CMNaran SAdetayo OAPollack IFLosee JE: Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. Clinical article. J Neurosurg Pediatr [epub ahead of print June 6 2014. DOI: 10.3171/2014.5.PEDS13414]

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