Paul Ransom wrote:
> Conventionally, I understood, skull x-rays were requested in infants
> because it is uncommon to have skull fractures caused by a fall in a
> non-mobile age group, and a screen for NAI was necessary. There are
> certainly 5 month olds who roll, and certainly some who roll off the bed,
> but surely the combination of a "roll" and a fracture would prompt some
> consideration for NAI and trigger thoughts of admission.

Yes Paul there is the issue of NAI screening, but that is a slightly
different subject, I was trying to restrict my argument to the pure medical
principle of whether and to what extent skull x-rays are useful in guiding
the medical management of the injured child (and in my particular case NAI
seemed very unlikely).

> Are children more prone to skull fractures than adults? I would have
> thought that the skull in young children would have acted like ribs,
> springier, and led to relatively greater intracerebral injury for the same
> force.

I'm not sure if there is any evidence for this Paul, it's very difficult to
study. However my point is not about the primary brain injury, we do skull
x-rays mainly to help us predict secondary brain injury. We can identify
primary brain injury by careful neurologic history and examination, and
sometimes by CT. I take it that you're suggesting that the absence of a
skull fracture cannot be taken as reassurance. I can loosely accept that but
this approach does not advance one's management of a particular case i.e.
taking this argument to its logical conclusion suggests that there's no
point in doing skull films at all as you will worry about brain injury
despite normal skull films, so you might as well just admit or scan them
all! This is clearly not tenable or practical in the paediatric population.

Bill Bailey wrote:
> Is there not a danger that a normal skull XR in this situation could lull
> you into a false sense of security?
> I would suggest that the decision to admit for neuro obs [if there is no
> indication for CT or it isn't available], should be based upon clinical
> findings rather than skull XR or you run the risk of discharging a child
> with a significant brain injury on the basis of a normal skull XR.

But that's assuming I would discharge a kid with neuro symptoms or signs
just because his skull x-ray was normal! Perhaps a normal skull x-ray might
reassure the unwary (much as normal ECGs and troponins do) but the canny
practitioner will not even do a skull x-ray if the kid seems a bit dodgy.
Such kids should be carefully observed with a low threshold for CT, i.e. the
skull film will not alter your management in such cases so I agree it
shouldn't be done in the first place.

Adrian Fogarty