Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes
Authors: Bonfield Christopher M. , Naran Sanjay , Adetayo Oluwaseun A. , Pollack Ian F. , Losee Joseph E. 
Published: June 2014

Object
Head trauma is a common cause of morbidity and mortality in the pediatric population and often results in a skull fracture. Pediatric skull fractures are distinct from adult fractures. Pediatric fractures have a greater capacity to remodel, but the pediatric brain and craniofacial skeleton are still developing. Although pediatric head trauma has been extensively studied, there is sparse literature regarding skull fractures. The authors' aim was to investigate the characteristics, injuries, complications, and outcomes of the patients in whom surgical intervention was needed for skull fractures.

Methods
The authors performed a retrospective review of patients presenting to the emergency department of a pediatric Level I trauma center between 2000 and 2005 with skull fractures. Patient demographics, mechanism of injury, associated injuries, fracture bone involvement, surgical intervention, complications, and outcomes were analyzed. Groups treated nonoperatively, for skull fracture repair, and for traumatic brain injury were compared.

Results
A total of 897 patients with a skull fracture were analyzed. Most patients (n = 772, 86.1%) were treated nonoperatively (Non-Op group). Fifty-eight patients (6.5%) underwent repair of the fracture (Repair group) and 67 (7.5%) required intervention for treatment of traumatic brain injury (TBI group). The Non-Op group was significantly younger, and the TBI group had a lower initial Glasgow Coma Scale (GCS) score. A fall (51.2%) was the most common mechanism of injury in the Non-Op group, whereas a motor vehicle crash (23.9%) and being hit in the head with an object (48.2%) were most prevalent in the TBI and Repair groups, respectively. Associated injuries were seen in all 3 groups, with brain injury (hematoma) being the most common. Frontal bone fracture was seen most in the Repair and TBI groups, and the parietal bone was the most frequent bone fractured in the Non-Op group. Patients in the TBI group were much more likely to have 2 or 3 skull bones fractured. In the Repair group, 36.2% had a complication (38.0% intervention related and 62.0% trauma related), but no patient had a worsening of their neurological status. In the TBI group, 48.7% of the patients suffered a complication, the vast majority (90.6%) of which were related to the trauma.

Conclusions
The majority of pediatric skull fractures can be managed conservatively. Of those requiring surgical intervention, fewer than half of the surgeries are performed solely for skull fracture repair only. 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 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. Complications occurred but most were related to underlying trauma, not the surgery. No patients who underwent intervention for repair of their skull fracture only had a worsening of their neurological status.