Editorial: Do skull fractures matter?

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 shortand 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. (http://thejns.org/doi/abs/10.3171/2014.3.PEDS14104)