Linear nondisplaced skull fractures in children: who should be observed or admitted?

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OBJECT

In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed.

METHODS

After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children’s hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus.

RESULTS

Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7–395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2–43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit.

CONCLUSIONS

Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.

ABBREVIATIONSCMHH = Children’s Memorial Hermann Hospital; CONSORT = Consolidated Standards for Reporting of Trials; CPS = Child Protective Service; LOS = length of stay; MOI = mechanism of injury; NDSF = nondisplaced skull fracture.

Abstract

OBJECT

In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed.

METHODS

After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children’s hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus.

RESULTS

Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7–395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2–43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit.

CONCLUSIONS

Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.

Head trauma is an important cause of morbidity and mortality in the pediatric population of the US, with an annual death toll estimated at more than 3000 patient deaths and well over 650,000 emergency department visits annually.12,19 It is estimated that pediatric traumatic brain injuries amount to more than $1 billion in hospital charges each year.16 While an overwhelming majority of these head injuries are considered mild, minor head injuries represent almost 400,000 emergency department visits annually.1,19 Livingston et al. estimated that if patients with isolated minor head injuries, a negative head CT scan, and no other intracranial pathologies were discharged from the emergency department, there could be a potential decrease in more than 500,000 hospital admissions each year.9 Although the idea that patients with isolated nondisplaced skull fractures (NDSFs) can be safely discharged home with no adverse neurological effects is generally well accepted, this is not the common practice among many institutions.

Linear NDSFs are common in pediatric patients after head trauma and do not require neurosurgical intervention. The disposition of patients with NDSFs varies by institution and even within the same institution. Some patients are admitted to a hospital inpatient unit or kept for 23-hour observation, and others are discharged home from emergency departments.2,6,8,10,15,17 The objective of this study was to review disposition data on children with NDSFs at a single, busy pediatric trauma center and to assess factors associated with the observation and hospitalization of these patients as well as costs of care.

Methods

After obtaining institutional review board approval, we retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at Children’s Memorial Hermann Hospital (CMHH) in Houston, Texas, between January 2009 and December 2013. All patients had received a CT scan at the time of diagnosis that clearly showed the NDSF in the bone window and any other intracranial pathology in the brain window. If a patient arrived at our center with only plain skull radiographs that demonstrated a fracture, then a CT scan was performed upon arrival. Patients with a single nondisplaced calvarial fracture were included in this study. Patients with isolated NDSFs and simultaneous non-CNS injuries (such as orthopedic injuries) were included in the study. Linear skull fractures that crossed a suture line but did not have associated intracranial hemorrhage or other exclusion criteria were included. Patients with open or comminuted skull fractures, intracranial hemorrhage, multiple skull fractures, or pneumocephalus (defined as intracranial air) were excluded. Any quantity of intracranial hemorrhage or pneumocephalus, no matter how small, was sufficient for exclusion from this study. Patients with any other intracranial or cervical pathology such as hydrocephalus, brain tumors, head or neck vascular injuries, or cervical spine fractures were also excluded. Notes from patient encounters such as emergency department visits, neurosurgical consults, hospital admission notes, social work notes, and postdischarge follow-up visits were reviewed. To assess costs associated with patient care, we collected data on the admitting hospital unit for each patient, the hospital length of stay (LOS), and means of arrival of each patient to the hospital.

Results

Patient Demographics

A total of 948 patients presented to CMHH between January 2009 and December 2013 with a diagnosis of traumatic brain injury. Of these 948 patients, 326 met inclusion criteria for this study. Figure 1 is a Consolidated Standards for Reporting of Trials (CONSORT) profile defining these patients’ exclusion criteria. One hundred thirty-four patients were excluded because fractures were depressed, multiple, or comminuted. Thirteen patients were excluded because fractures were open. Forty-three additional patients were excluded for pneumocephalus, 133 for intracranial hemorrhage, and 96 because a skull fracture was not definitive on review of imaging studies. Patient demographics are summarized in Table 1. The majority of the patients were male (59%), and the largest ethnicity represented was patients of Hispanic descent (45%). Median age at time of evaluation was 19 months (age range 2 weeks to 15 years).

FIG. 1.
FIG. 1.

CONSORT profile defining the patient exclusion criteria. The arrows represent the flow of patients throughout this process.

TABLE 1.

Summary of patient demographics

DemographicsValue
Age
 Median19 mos
 Range2 wks–15 yrs
Sex (M/F)193/133
Race/ethnicity
 African American27
 Asian16
 Caucasian126
 Hispanic148
 Other*9
Insurance
 Private119
 Medicaid189
 None18

Racial groups represented by only 2 patients or fewer.

Hospital Encounter

Of the 326 patients who met inclusion criteria, 56% (n = 184) were placed under 23-hour observation status, 27% (n = 87) were admitted to the hospital floor, and 17% (n = 55) were discharged from the emergency department. No discharged patient in this study required repeat admission. Less than 16% (n = 50) were followed up in the pediatric neurosurgery clinic after discharge. All 50 of these patients were neurologically intact at the time of the follow-up visit. Seventy-nine percent (n = 257) of the patients were transferred from another institution. Seventy-six percent (n = 42) of the patients who were discharged from the emergency department were initially transferred from a community hospital to CMHH. Eighty-five percent (n = 278) of the patients arrived at the hospital by ambulance, 11% (n = 36) arrived by car, and 4% (n = 12) were airlifted by helicopter to the hospital.

According to the history provided at the time of presentation to the emergency department, 14% of patients (n = 45) had altered mental status or loss of consciousness, 21% (n = 68) had at least 1 episode of vomiting after head trauma, and 2% (n = 8) had witnessed seizures or seizure-like activity after head trauma. No patient had any neurological deficits at the time of admission, and none required any neurosurgical intervention. The mean hospital LOS for patients admitted to the inpatient unit was 46 hours, and the mean LOS for patients placed under 23-hour observation status was 18 hours (Table 2). The LOS for patients in the inpatient unit ranged from 7 hours to 16 days. The longest time a patient spent in the observation unit was 43 hours.

TABLE 2.

Summary of hospital LOS

Admitting Hospital UnitMean Hospital LOS (hrs)Range (hrs)
Inpatient unit467–395
23-hr observation182–43

Child protective service (CPS) involvement was a cause of extended hospitalization in 7% (n = 24) of patients in this study. Three percent of patients (n = 11) experienced extended hospitalization because of other injuries. Additional injuries in this patient group are listed in Table 3.

TABLE 3.

Patients with other injuries

Type of InjuryLOS (hrs)
Rt open tibia-fibular fracture, rt scapular wing fracture, tiny Grade I liver laceration, multiple mild lt pulmonary contusions & small amount of free fluid in pelvis37
Lt humerus film: displaced mid-shaft humerus fracture46
Rt orbital wall fracture, lt upper neck emphysema & masticator space emphysema w/o obvious skin laceration67
Rt 5th rib fracture & possible fracture of the anterolateral aspect of lt 7th rib w/ unknown MOI67
Rt distal radius Salter II fracture70
Rt superior inferior pubic ramus fracture, rt nondisplaced clavicle fracture, rt oblique tibia-fibular fracture74
Lt humeral fracture & multiple fractures of distal long bones & ribs83
Comminuted fracture of lt iliac wing w/ extension to lt sacroiliac joint95
Lt lower extremity soft-tissue avulsion w/joint exposure182
Grade 3 liver laceration, Grade 2 spleen laceration, rt lower lobe contusion, small hemothorax, and rt pneumothorax245
Grade 2 laceration of spleen, laceration of body of pancreas, rt adrenal hematoma, healing rt 11th rib fracture, Grade 3 colonic injury, & Grade 1 duodenal injury395

Mechanism of Injury

Mechanism of injury (MOI) for patients who met inclusion criteria is summarized in Table 4. Falls were the most common cause of head injury across all patient groups. A total of 230 patients (71%) sustained their head injury after a fall. Seven percent (n = 23) of these were specifically due to a fall from a shopping cart. The 3 most common MOIs sustained by patients placed under 23-hour observation were falls (n = 143), dropped by a caregiver (n = 12), and object to the head (n = 9). For patients admitted to the hospital floor, the most common MOIs were falls (n = 46), possible nonaccidental trauma (n = 20), and object to head (n = 6).

TABLE 4.

Mechanism of injury

MOIAdmitting Hospital Unit (%)Discharged (%)No. of Patients
23-Hr ObservationInpatient Unit
Fall (general)128 (62)44 (21)35 (17)207
Fall from shopping cart15 (65)2 (9)6 (26)23
Dropped by caregiver12 (63)5 (26)2 (11)19
MVA4 (57)2 (29)1 (14)7
Pedestrian vs auto3 (38)4 (50)1 (12)8
Bicycle vs auto4 (67)2 (33)None6
Sports-related4 (57)2 (29)1 (14)7
ATV-relatedNoneNone3 (100)3
Object to the head9 (56)6 (38)1 (6)16
Unknown history/possible NAT5 (17)20 (69)4 (14)29
Kicked by horseNoneNone1 (100)1
Totals184 (56)87 (27)55 (17)326

ATV = all-terrain vehicle; auto = automobile; MVA = motor vehicle accident; NAT = nonaccidental trauma.

Location of Skull Fracture

Fracture locations are summarized in Table 5. Overall, the most common locations for an NDSF in this study were the occipital bone (n = 126), the parietal bone (n = 102), and the frontal bone (n = 58). Four percent of the patients had a nondisplaced frontal bone that extended to the orbital rim (n = 14) and 5% (n = 17) had a single fracture involving 2 bones. There were no frontal bone fractures that involved the frontal sinuses in this study.

TABLE 5.

Fracture location

Fracture LocationAdmitting Hospital Unit (%)Discharged (%)Total No. of Patients
23-Hr ObservationInpatient Unit
Frontal bone29 (66)6 (14)9 (20)44
Frontal bone fracture involving orbital rim9 (64)3 (21)2 (14)14
Parietal bone53 (52)30 (29)19 (19)102
Temporal bone13 (57)7 (30)3 (13)23
Occipital bone70 (56)35 (28)21 (17)126
Single fracture involving 2 bones10 (59)6 (35)1 (6)17
Totals184 (56)87 (27)55 (17)326

Hospital Cost Assessment

The current room charge per hour and staffing at CMHH’s inpatient unit is $782 per day, not including supplies and medications. The observation unit can cost as much as $1283 if a patient spends up to 24 hours in observation. The average LOS for patients under observation in this study was 18 hours, and 46 hours for patients in the inpatient unit, adjusting the mean costs to $962.25 and $1498.83 respectively.

Discussion

While previous studies have reviewed large series of children with skull fractures, this is the largest study specifically focusing on linear NDSFs and excluding more serious injuries. We hypothesized that some hospitalizations in these patients can be safely avoided and that avoiding such hospitalizations could render considerable cost savings. The majority of the patients in this retrospective study were male, Hispanic, and insured by Medicaid. These findings are reflective of the community our hospital serves. The most common MOI in our study was falls, which has been noted as a predominant cause of skull fractures in previous publications.3,4,10 In their large series, Bonfield et al. noted that high-impact injuries such as motor vehicle collisions or objects to the head have a higher potential to cause depressed or open skull fractures that may require neurosurgical intervention.3 Nonetheless, patients with isolated NDSFs require no neurosurgical intervention and may not require hospitalization.

The most important finding of this study, as expected, was that none of the 326 patients had a neurological deficit at any point in their management, and none required neurosurgical intervention. An obvious limitation of these data is that only 16% of patients had follow-up outpatient visits after their hospitalization. This low follow-up rate is directly related to our practice pattern, which does not include mandatory follow-up appointments in this population. At our hospital, when a patient with an NDSF is discharged from the emergency department or hospital, the parents are told to bring the patient back to the emergency department or outpatient clinic only if new signs or symptoms arise. While it is theoretically possible that some of the patients without follow-up had new signs or symptoms that were assessed in outside hospitals, it is highly unlikely that this happened in a large number of patients.

Given the fact that no patient with an NDSF required neurosurgical intervention and none had a neurological deficit, the obvious question is why only 17% of patients were discharged from the emergency department and the remainder were hospitalized or kept for 23-hour inpatient observation. There are a variety of factors that influenced this statistic. Certainly, any patient with suspicion of nonaccidental injury cannot be sent home to a potentially unsafe environment, as nonaccidental injury claims the lives of more than 280 children each year in the US.5 In this cohort, 7% of patients required extended hospitalization due to CPS input. However, many of the observation patients were held in observation status pending a nonaccidental trauma evaluation without specific CPS involvement. Four percent of patients required extended hospitalization due to non-CNS injuries. Other possible explanations for hospitalization or 23-hour observation were episodes of vomiting (21%), history of altered mental status (14%), or possible seizure activity (2%). Some of these symptoms, as well as headaches, dizziness, and poor memory or concentration, may persist for days to weeks in patients after minor head injuries.8,20,21 While these symptoms do not typically portend the need for neurosurgical intervention in patients who are neurologically intact and do not have intracranial hemorrhage or other injury, practitioners are understandably reluctant to send patients home who are symptomatic soon after a head trauma. Some emergency medicine guidelines suggest that children less than 2 years of age should be observed for 4 to 6 hours in the hospital and discharged if asymptomatic and neurologically intact after this period of observation.8

Seventy-eight percent of patients were transferred from outside hospitals, either by ambulance (85%) or even helicopter (4%), and many parents presumably arrived with the expectation that a higher level of care and possibly intervention would be required for their child. It is often easier for practitioners to simply admit these patients to the hospital unit or keep them for 23-hour observation status, particularly when patients arrive in the middle of the night, rather than explain to parents that such transfers were not necessary. While patients should be transferred from community hospitals if treating physicians do not feel comfortable with their management, clearly there is room for improvement in educating some physicians in these hospitals about the natural history of isolated NDSFs and the unlikely need for intervention.

Not all community hospitals have a neurosurgical team onsite to manage a patient with a skull fracture, and some centers are uncomfortable or not equipped to care for children with head injuries. Thus, some community hospitals have no other option but to transfer patients with skull fractures to higher-level trauma centers where these patients can be properly observed and managed. Placing a patient under observation status assumes that the observation will “uncover a reasonable percentage of occult injuries not found on diagnostic testing amenable to prompt intervention, thereby reducing complications and death.” 9 A multicenter retrospective review of patients admitted for minor head injuries reported that more than a third of the patients were missing documented observation. 18 Current emergency guidelines strongly encourage community hospitals to initiate rapid referrals to pediatric trauma centers whenever ongoing reassessment and definitive management of admitted patients with head trauma cannot be met by the community facility. 8 An important finding in our study was that 76% (n = 42) of patients discharged upon arrival to our center had been transferred from an outside hospital for a higher level of care. As most hospital transfers employ the use of ambulance and helicopter services, these transfers create a significant financial burden for families and insurance companies. As part of our cost assessment, we reviewed the standard charge rates by the Houston Fire Department and Life-Flight helicopter services in our area. The Houston Fire Department’s ambulance service cost $1000 (base rate) plus $13 per mile, and the Life-Flight helicopter service cost $11,902.82 (base rate) plus $118.98 per mile. 11, 13 At least in some cases, it is clear that these hospital transfers, and their extensive costs, were not medically necessary. In an effort to minimize interhospital transfers and the use of hospital resources, the Primary Children’s Hospital in Salt Lake City, Utah, institutionalized a “Management Algorithm for Isolated Skull Fractures” in January 2012. 10 The new guideline criteria for admission included vomiting, abnormal neurological examination results, possible nonaccidental injury, and high-energy injury mechanisms. These guidelines recommended rapid discharge of patients with an isolated skull fracture, a normal neurological examination, no high-energy MOI, and no other non-CNS injuries. In their prospective study on the impact of these new guidelines, Metzger et al. were able to identify an 18% decrease in overall admission rates of patients with isolated skull fractures with no compromise to patient safety. 10 Although this was a “modest” decrease in admission rates compared with years prior, Metzger et al. do agree that “there [still] exists the potential to further reduce the admission rates… for these patients.” 10

Conclusions

In conclusion, 23-hour observation or hospitalization for many children with NDSFs is costly and not always necessary. As demonstrated in this study and previously published reports, the likelihood of missing a delayed hemorrhage or other life-threatening complication in patients with isolated NDSFs is extremely low. 7,9,14 Based upon the findings in this review, we plan to attempt to find ways to minimize hospital transfers and admissions for isolated NDSFs, and we hypothesize that doing so would be worthwhile at other centers as well.

Acknowledgment

The participation of Eliel N. Arrey, BS, in this project was supported by the University of Texas Health-Science Center Summer Research Program Grant. This grant is funded by the National Institute of Neurological Diseases and Stroke (NIH Award no. 5 T35 NS 64931-5)

Author Contributions

Conception and design: Sandberg, Arrey, Kerr. Acquisition of data: Arrey, Kerr. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: Sandberg, Kerr, Fletcher, Cox. Reviewed submitted version of manuscript: all authors. Statistical analysis: Arrey. Administrative/technical/material support: Kerr. Study supervision: Sandberg, Kerr, Fletcher, Cox.

References

  • 1

    Bazarian JJMcClung JShah MNCheng YTFlesher WKraus J: Mild traumatic brain injury in the United States, 1998--2000. Brain Inj 19:85912005

  • 2

    Beaudin MSaint-Vil DOuimet AMercier CCrevier L: Clinical algorithm and resource use in the management of children with minor head trauma. J Pediatr Surg 42:8498522007

  • 3

    Bonfleld CMNaran SAdetayo OAPollack IFLosee JE: Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr 14:2052112014

  • 4

    Erşahin YMutluer SMirzai HPalali I: Pediatric depressed skull fractures: analysis of 530 cases. Childs Nerv Syst 12:3233311996

  • 5

    Graupman PWinston KR: Nonaccidental head trauma as a cause of childhood death. J Neurosurg 104:4 Suppl2452502006

  • 6

    Greenes DSSchutzman SA: Clinical indicators of intracranial injury in head-injured infants. Pediatrics 104:8618671999

  • 7

    Hassan SFCohn SMAdmire JNunez-Cantu OArar YMyers JG: Natural history and clinical implications of nondepressed skull fracture in young children. J Trauma Acute Care Surg 77:1661692014

  • 8

    Hung GRMinor head injury in infants and children. Tintinalli JEStapczynski JSCline DM: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 7New YorkMcGraw-Hill2011

  • 9

    Livingston DHLavery RFPassannante MRSkurnick JHBaker SFabian TC: Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. Ann Surg 232:1261322000

  • 10

    Metzger RRSmith JWells MEldridge LHolsti MScaife ER: Impact of newly adopted guidelines for management of children with isolated skull fracture. J Pediatr Surg 49:185618602014

  • 11

    Moran C: Council OKs $13-a-mile ambulance charge. Houston Chronicle May22012. (http://www.chron.com/news/houston-texas/article/Council-OKs-13-a-mile-ambulance-charge-3530058.php

  • 12

    National Center for Injury Prevention and Control: Traumatic Brain Injury in the United States: Assessing Outcomes in Children AtlantaCenters for Disease Control and Prevention2000. (http://www.cdc.gov/traumaticbraininjury/assessing_outcomes_in_children.html)

  • 13

    O’Halloran M: Expense outrage: the cost of life-flight ambulance services. WJHG 2010. February 27 (http://www.wjhg.com/home/headlines/85584502.html)

  • 14

    Rollins MDBarnhart DCGreenberg RAScaife ERHolsti MMeyers RL: Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg 46:134213462011

  • 15

    Schnadower DVazquez HLee JDayan PRoskind CG: Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr 19:2582642007

  • 16

    Schneier AJShields BJHostetler SGXiang HSmith GA: Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 118:4834922006

  • 17

    Schutzman SABarnes PDuhaime ACGreenes DHomer CJaffe D: Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 107:9839932001

  • 18

    Shackford SRWald SLRoss SECogbill THHoyt DBMorris JA: The clinical utility of computed tomograph-ic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 33:3853941992

  • 19

    Thiessen MLWoolridge DP: Pediatric minor closed head injury. Pediatr Clin North Am 53:126v2006

  • 20

    Yeates KOKaizar ERusin JBangert BDietrich ANuss K: Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med 166:6156222012

  • 21

    Yeates KOTaylor HGRusin JBangert BDietrich ANuss K: Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics 123:7357432009

Article Information

Correspondence David I. Sandberg, Department of Pediatric Neurosurgery, University of Texas Health Center at Houston, 6431 Fannin St., MSB 5.144, Houston, TX 77030. email: david.i.sandberg@uth.tmc.edu.

INCLUDE WHEN CITING Published online September 4, 2015; DOI: 10.3171/2015.4.PEDS1545.

Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    CONSORT profile defining the patient exclusion criteria. The arrows represent the flow of patients throughout this process.

References

1

Bazarian JJMcClung JShah MNCheng YTFlesher WKraus J: Mild traumatic brain injury in the United States, 1998--2000. Brain Inj 19:85912005

2

Beaudin MSaint-Vil DOuimet AMercier CCrevier L: Clinical algorithm and resource use in the management of children with minor head trauma. J Pediatr Surg 42:8498522007

3

Bonfleld CMNaran SAdetayo OAPollack IFLosee JE: Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr 14:2052112014

4

Erşahin YMutluer SMirzai HPalali I: Pediatric depressed skull fractures: analysis of 530 cases. Childs Nerv Syst 12:3233311996

5

Graupman PWinston KR: Nonaccidental head trauma as a cause of childhood death. J Neurosurg 104:4 Suppl2452502006

6

Greenes DSSchutzman SA: Clinical indicators of intracranial injury in head-injured infants. Pediatrics 104:8618671999

7

Hassan SFCohn SMAdmire JNunez-Cantu OArar YMyers JG: Natural history and clinical implications of nondepressed skull fracture in young children. J Trauma Acute Care Surg 77:1661692014

8

Hung GRMinor head injury in infants and children. Tintinalli JEStapczynski JSCline DM: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 7New YorkMcGraw-Hill2011

9

Livingston DHLavery RFPassannante MRSkurnick JHBaker SFabian TC: Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. Ann Surg 232:1261322000

10

Metzger RRSmith JWells MEldridge LHolsti MScaife ER: Impact of newly adopted guidelines for management of children with isolated skull fracture. J Pediatr Surg 49:185618602014

11

Moran C: Council OKs $13-a-mile ambulance charge. Houston Chronicle May22012. (http://www.chron.com/news/houston-texas/article/Council-OKs-13-a-mile-ambulance-charge-3530058.php

12

National Center for Injury Prevention and Control: Traumatic Brain Injury in the United States: Assessing Outcomes in Children AtlantaCenters for Disease Control and Prevention2000. (http://www.cdc.gov/traumaticbraininjury/assessing_outcomes_in_children.html)

13

O’Halloran M: Expense outrage: the cost of life-flight ambulance services. WJHG 2010. February 27 (http://www.wjhg.com/home/headlines/85584502.html)

14

Rollins MDBarnhart DCGreenberg RAScaife ERHolsti MMeyers RL: Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg 46:134213462011

15

Schnadower DVazquez HLee JDayan PRoskind CG: Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr 19:2582642007

16

Schneier AJShields BJHostetler SGXiang HSmith GA: Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 118:4834922006

17

Schutzman SABarnes PDuhaime ACGreenes DHomer CJaffe D: Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 107:9839932001

18

Shackford SRWald SLRoss SECogbill THHoyt DBMorris JA: The clinical utility of computed tomograph-ic scanning and neurologic examination in the management of patients with minor head injuries. J Trauma 33:3853941992

19

Thiessen MLWoolridge DP: Pediatric minor closed head injury. Pediatr Clin North Am 53:126v2006

20

Yeates KOKaizar ERusin JBangert BDietrich ANuss K: Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med 166:6156222012

21

Yeates KOTaylor HGRusin JBangert BDietrich ANuss K: Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status. Pediatrics 123:7357432009

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