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 Childrens 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 DEMOGRAPHICS
Treatment group (%)
variable
sex

race

age

Non op

Repair

Tbi

all

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)

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)

8.5

8.6

5.9

0.117.6

0.121.7

5.2

5.1

Mean

5.5

Range

0.121.7 0.117.7

sd

5.0

4.8

HOSPITAL STAY DATA

Treatment group (%)
Variable
Gcs score
on
admisiion

Los (day )
*

Non op

repair

tbi

all

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

Icu
150
admission (19.4)
*

24 (41.4)

63 (94.0)

237
(26.4)

intubated

12 (20.7)

42 (62.7)

131
(14.6)

16.0

3.4

77 (10.0)

Mean

2.1

5.3

Range

0 40.0

137

sd

3.6

7.0

065
13.0

4.0

065
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)

Nat

33 (4.3)

Object to head

6 (10.3)

16 (23.9)
0 (0.0)

130 (16.8)

28 (48.2)

107 (11.9)
6 (9.0)

39 (4.3)

12 (17.9)

170 (19.0)

8 (11.9)

50 (5.6)

Pedestrian vs mvc

39 (5.1)

3 (5.2)

Rollerblade
/skateboard
accident

12 (1.6)

0 (0.0)

2 (3.0)

14 (1.6)

2 (3.4)

0 (0.0)

2 (0.2)

2 (3.4)

1 (1.5)

30 (3.3)

0 (0.0)

Sledding accident
Sport collision
total

27 (3.5)
772 (100)

58 (100)

67 (100)

897 (100)

Fracture location
TREATMENT 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 (%)
ASSOSIAT NON OP
ED INJURY
intracranial hematoma

REPAIR

TBI

ALL

P VALUE

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 (1.5)

24 (2.7)

ophthalmological

31 (4.0)

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

1 (1.7)
6 (10.3)

1.0

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