Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Medical College of Georgia

Pearl: While computerized axial tomography scans are reasonable for detecting pediatric skull fractures, they are not perfect. However, reconstruction of the CT scan images with the newer scanners provides excellent visualization of pediatric skull fractures.

Presentation: A 14-month-old girl presented to the pediatric emergency department for evaluation of a large swelling on the side of her head. (Figure 1.) The day before, she was seen at another hospital and had a CT scan, which failed to detect a skull fracture. A repeat CT scan was performed, and reconstruction of the images was requested to specifically look for a skull fracture. When the CT scan was reconstructed, the fracture was visualized easily. A skull fracture was noted running parallel to the sagittal suture and crossing the lambdoid suture. (Figure 2.)

Discussion: Because severe intracranial injury can occur in the absence of skull fracture and skull radiography is not a reliable predictor of intracranial injury, a CT scan generally is recommended if imaging is required.^1,2,3,4 Consequently, the use of skull films has waned in the evaluation of pediatric skull fractures. Instead, computerized axial tomography now is recommended for the diagnosis of skull fractures. Unfortunately, when it comes to documenting pediatric skull fractures, CT scans are not perfect. ^5,6 Fractures at the skull vertex seem to be missed more easily on CT scans but may be depicted on plain radiographs. ⁷ It is well known that basilar skull fractures may be missed on CT scan; however, a linear or minimally depressed fracture also may be overlooked easily on CT (particularly when viewed with narrow windows). ⁷ A streak artifact caused by a misaligned fracture may be a clue to the presence of a fracture. ⁷ However, if the radiologist reconstructs the images, the fractures often are much more obvious.

References:

1. Lloyd DA, Carty H, Patterson M, et al. Predictive value of skull radiography for intracranial injury in children with blunt head injury. Lancet 1997;349:821-4.
2. Simon B, Letourneau P, Vitorino E, et al. Pediatric minor head trauma: indications for computed tomographic scanning revisited. J Trauma 2001;51:231-7; discussion 237-8.
3. Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983-93.
4. http://www.bestbets.org/bets/bet.php?id=53
5. Fleece DM, Kochan PS. Skull fracture in an infant not visible with computed tomography. J Pediatr 2009;154:934.
6. Pathak A, Singh D, Khandelwal N. Fallacies of routine CT scan in identifying lesions in severe head injury. Indian Journal of Neurotrauma (IJNT) 2006;3:37-42.
7. http://emedicine.medscape.com/article/343764-imaging
8. Markose E, Vikraman B, Veerabahu M. Three dimensional CT reconstruction: a comparison between 2D, 3D CT and original anatomical structures J Maxillofacial Oral Sur 2009;8:8-12.
9. Fatterpekar GM, Doshi AH, Dugar M, et al. Role of 3D CT in the evaluation of the temporal bone. Radiographics 2006;26 Suppl 1:S117-32.

Online Resource:

1. http://emedicine.medscape.com/article/343764-overview

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