Infants with isolated skull fracture: what are their clinical characteristics, and do they require hospitalization?

STUDY
OBJECTIVE: We sought to identify the historical factors and physical examination findings typical of infants who have sustained isolated skull fracture (ISF)--in the absence of associated intracranial injury--after head trauma. We also assessed the risk of clinical deterioration (and therefore the need for inpatient observation) in infants with ISF.
METHODS: We conducted a retrospective analysis of all patients younger than 2 years admitted to a tertiary care pediatric hospital with a diagnosis of ISF over a 3-year period.
RESULTS: During the study period, 101 infants with radiographically proven ISF were admitted to the hospital. Falls were the most common reported mechanism of injury (n = 90 [89%]). Many falls involved short distances: 18 patients (18%) fell less than 3 feet. Nonaccidental trauma was suspected in only 10 patients (10%). Seventy-two patients (71%; 95% confidence interval [CI], 61%, 79%) had at least one of the clinical signs considered potential indicators of serious head injury: initial loss of consciousness, seizures, vomiting, lethargy, irritability, depressed mental status, and focal neurologic findings. In 97 patients (96%; 95% CI, 89%, 98%), local findings of head injury (palpable fracture, soft-tissue swelling, or signs of basilar skull fracture) were noted on physical examination. None of the patients (0%; 95% CI, 0%, 3%) demonstrated clinical decline during hospitalization. All were neurologically normal on discharge.
CONCLUSION: A diagnosis of ISF should be considered even in infants with minor mechanisms of head injury who appear well. However, infants with ISF rarely present without local signs of head injury on physical examination. If no other specific clinical concerns necessitate hospital admission, infants with ISF who have reliable caretakers may be considered for discharge home.