PEDIATRIC SKULL FRACTURES: THE NEED FOR SURGICAL INTERVENTION, CHARACTERISTICS, COMPLICATIONS, AND OUTCOMES

Clinical article

introduction

• Head trauma is common in the pediatric population and is an important cause of morbidity and mortality in the United States, with an estimated – Incidence of 250 per 100,000 per year– over 7000 deaths, – 60,000 hospitalizations, and – 600,000 emergency department visits annually

among American children.• In children, between 10%–30% of head injuries

result in skull fracture, many with associated brain injury

Surgical intervention is largely performed in cases of skull fracture depression, frontal sinus involvement, and underlying mass lesion.

Pediatric skull fractures have a greater capacity to heal and remodel, but the pediatric brain and craniofacial skeleton are also still developing, which puts the children at risk for unique complications, such as growing skull fractures

there is sparse literature regarding skull fractures, the rate of operative management, and outcomes following surgical intervention in this population.

Methods

A database of all patients diagnosed with a skull fracture at the Children’s Hospital of Pittsburgh from 2000 to 2005 was searched.

All patients diagnosed with a skull fracture were included regardless of treating specialty, treatment modality, or need for hospital admission.

Patient demographics, mechanism of injury, associated injuries, fracture bone involvement, surgical intervention, complications, and outcomes were recorded.

Comparison was made between individuals who were treated nonoperatively (Non-Op group), those surgically treated for skull fracture repair only (Repair group), and those surgically treated for traumatic brain injury (TBI) with or without repair of a skull fracture (TBI group)

Data analysis was performed using SPSS version 17 (SPSS, Inc.). Chi-square tests were used for the between- group comparisons of categorical variables. Since age, length of hospital stay, and Glasgow Coma Scale (GCS) score were not normally distributed, Kruskal-Wallis tests were used for the comparisons of continuous variables. Mean values presented ± SD

Results

Patient Characteristics Hospital Stay Data Mechanism of Injury Fracture Location Associated Injuries Procedures

Results

A total of 897 patients between 2000 and 2005 with a diagnosis of a skull fracture. • Of these patients, 772 (86.1%) were

treated nonoperatively (Non-Op group). • 58 patients (6.5%) underwent repair of the

fracture (Repair group)• 67 patients (7.5%) required intervention for

treatment of a TBI (TBI group)

PATIENT DEMOGRAPHICSTreatment group (%)

variable Non op Repair Tbi all

sex Male 490 (63.4)

40 (69.0) 44 (65.7) 574 (64.0)

Female 282 (36.5)

18 (31.0) 23 (34.3) 323 (36.0)

Total 772 (100)

58 (100) 67 (100) 897 (100)

race White 635 (82.3)

47 (81.0) 57 (85.1) 739 (82.4)

Black 86 (11.1) 8 (13.8) 6 (9.0) 100 (11.1)

Other 51 (6.7) 3 (5.2) 4 (6.0) 58 (6.5)

age Mean 5.5 8.5 8.6 5.9

Range 0.1–21.7 0.1–17.7 0.1–17.6 0.1–21.7

sd 5.0 4.8 5.2 5.1

HOSPITAL STAY DATA

Treatment group (%)

Variable Non op repair tbi all

Gcs score on admisiion

Mean 13.6 12.4 6.8 13.0

Range 3-15 3-15 3-15 3-15

Sd 3.4 4.6 4.5 4.0

Icu admission*

150 (19.4)

24 (41.4) 63 (94.0) 237 (26.4)

intubated 77 (10.0) 12 (20.7) 42 (62.7) 131 (14.6)

Los (day )*

Mean 2.1 5.3 16.0 3.4

Range 0– 40.0 1–37 0–65 0–65

sd 3.6 7.0 13.0 6.4

MECHANISM OF INJURY

Treatment group (%)

Variable Non op Repair Tbi All

Atv 23 (3.0) 2 (3.4) 4 (6.0) 29 (3.2)

Bycicle accident 18 (2.3) 5 (8.6) 4 (6.0) 27 (3.0)

Fall 395 (51.2) 8 (13.8) 12 (17.9) 415 (46.3)

Gunshot wound 1 (0.1) 0 (0.0) 1 (1.5) 2 (0.2)

Lawnmower accident 0 (0.0) 1 (1.7) 0 (0.0) 1 (0.1)

Motorbike accident 9 (1.2) 1 (1.7) 1 (1.5) 11 (1.2)

Mvc 85 (11.0) 6 (10.3) 16 (23.9) 107 (11.9)

Nat 33 (4.3) 0 (0.0) 6 (9.0) 39 (4.3)

Object to head 130 (16.8) 28 (48.2) 12 (17.9) 170 (19.0)

Pedestrian vs mvc 39 (5.1) 3 (5.2) 8 (11.9) 50 (5.6)

Rollerblade /skateboard accident

12 (1.6) 0 (0.0) 2 (3.0) 14 (1.6)

Sledding accident 0 (0.0) 2 (3.4) 0 (0.0) 2 (0.2)

Sport collision 27 (3.5) 2 (3.4) 1 (1.5) 30 (3.3)

total 772 (100) 58 (100) 67 (100) 897 (100)

Fracture locationTREATMENT GROUPS (%)

Fracture location

Non op Repair TBI ALL

FRONTAL 188 (24.4) 36 (62.1) 18 (26.9) 242 (27.0)

TEMPORAL 129 (16.7) 5 (8.6) 11 (16.4) 145 (16.2)

PARIETAL 251 (32.5) 8 (13.8) 10 (14.9) 269 (30.0)

OCCIPITAL 108 (14.0) 1 (1.7) 7 (10.4) 116 (12.9)

2 BONES 85 (11.0) 8 (13.8) 16 (23.9) 109 (12.2)

3 BONES 11 (1.4) 0 (0.0) 5 (7.5) 16 (1.8)

ASSOSIATED INJURIES

TREATMENT GROUPS (%)

ASSOSIATED INJURY

NON OP REPAIR TBI ALL P VALUE

intracranial hematoma 326 (42.2) 23 (39.7) 57 (85.1) 406 (45.3) <0.0001

facial fracture 34 (4.4) 9 (15.5) 12 (17.9) 55 (6.1) <0.0001

spine 22 (2.9) 1 (1.7) 1 (1.5) 24 (2.7) 1.0

ophthalmological 31 (4.0) 6 (10.3) 12 (17.9) 49 (5.5) <0.0001

cardiac/pulmonary 24 (3.1) 1 (1.7) 19 (28.3) 44 (4.9) <0.0001

orthopedic 82 (10.6) 1 (1.7) 14 (20.9) 97 (10.8) <0.0001

abdominal/pelvic 22 (2.9) 1 (1.7) 17 (25.4) 40 (4.5) <0.0001

Complications in surgical groups

PATIENT TREATMENT GROUP

REPAIR TBI

SURGERY RELATED TRAUMA RELATED SURGERY RELATED TRAUMA RELATED

CONCERN OVER CRANIOTOMY DEFECT

DEEP VENOUS TROMBOSIS

CRANIOPLASTY REVISION AFTER RESORPTION

BEHAVIORAL PROBLEM

CSF LEAK AFTER GROWING SKULL FRACTURE REPAIR

NEW HEADACHE HARDWARE REMOVAL AFTER 18 MONTH LATER

DEATH

PAINFULL HARDWARE LEARNING DISABILITY WOUND INFECTION DEP VENOUS THROMBOSIS

REMOVAL OF HARDWARE 6 MONT LATER

MULTIPLE PROSEDUR FOR FACE / FOREHEAD SOFT TISSUE INJURY

SPLIT THICNESS SKIN GRAFT

HEADACHE

SALMONELLA MENINGITIS POST OP

SEIZURES MOTOR WEAKNESS

SCALP REVISION 4 YEARS LATER DUE TO DEHISCENCE

WORSENING OF MIGRAINES

LEARNING DISABILITY

WOUND REVISION AND HARDWARE REMOVAL 3 YEARS LATER DUE TO WIDENING SCAR AND PAIN

MOTOR WEAKNESS SEIZURES

WOUND INFECTION SPASTICITY

HIDROSEPHALUS

CONCLUSION

Although the vast majority of children with skull fractures do not require surgical intervention, it is important to understand the characteristics, indications, and patterns of those patients who do. Of the fractures requiring intervention, fewer than half are treated on the basis of skull fracture elevation repair only

CONCLUSION

Being hit in the head by an object is by the most common mechanism of a fracture needing repair and an MVC is the most common mechanism resulting in management of TBI.

Patients sustaining a frontal bone fracture or having multiple skull bones involved in the fracture are more likely to require surgical intervention.

CONCLUSION

The majority of complications are a direct result of the traumatic event, not the surgical inter

vention. No patients had worsening of a

neurological deficit after fracture repair, but complications such as painful hardware and wound infections did necessitate further interventions.

CONCLUSION

An understanding of this population with fractures will enable practitioners to better identify pa- tients who may need surgical intervention and to counsel patients regarding late sequelae of the trauma, fracture, and intervention