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. Can't remember
which (gruesome) study looked at the force necessary to fracture an infant's
skull, but seem to remember that about 5 ft was the usual height.
Are children are 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.
Paul Ransom, SpR A&E Hastings
---- Original Message -----
From: Adrian Fogarty <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, November 18, 2001 12:36 AM
Subject: Re: Head injuries
Maybe Bill, but consider the corollary of your argument. If we didn't x-ray
then surely this particular kid would've been discharged on the basis of
good clinical signs. However I believe she needed to be admitted despite her
good clinical picture, and so did the neurosurgeon. Remember I saw her
within two hours of injury, and her window of risk probably ran to at least
12 hours. I believe the decision to admit or discharge in such cases is very
much guided by x-ray findings. I think it's important to remember that
classic epidurals still occur. Such patients might have no LOC, and can be
clinically very well on presentation. Yet the skull fracture will lead to an
epidural over the next few hours. Clinical assessment is quite redundant in
such cases. Only the skull x-ray will alert you to the potential problem,
and such patients are far too well to CT. Conversely it is generally
accepted that a normal patient with a normal x-ray has a vanishingly small
risk of problems. Sure there is always that 1 in 10,000 patient who defies
the rules, but Bolam will protect us in such cases! Besides, we can't be
expected to treat 10,000 to achieve one benefit.
Adrian Fogarty
----- Original Message -----
From: Bill Bailey
To: [log in to unmask]
Sent: Sunday, November 18, 2001 4:39 AM
Subject: Re: Head injuries
Adrian
Is there not a danger that a normal skull XR in this situation could lull
you into a false sense of security? I was under the impression that the
correlation between skull fracture and significant intracerebral injury in
kids was significantly less than in adults, i.e. there will be more kids
with significant brain injury without a skull fracture.
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.
Best wishes
Bill Bailey
----- Original Message -----
From: Adrian Fogarty
To: [log in to unmask]
Sent: Friday, November 16, 2001 7:29 PM
Subject: Re: Head injuries
Original Message from Paul Bailey, 27th September 2001
> The real issue with skull films in my opinion is that they do not
answer the question that you need to ask..... which is: does this patient
have a clinically significant intracerebral injury that requires
neurosurgery? Sure, a skull fracture might alter the probabilities, but you
probably go from rare to slightly less rare.... Skull XRays are a relic of
the pre CT era for the vast majority of patients.... The evidence is that
in patients with rigidly defined minor head injury, and GCS of 15.....
approx 5-7% will have any form of CT abnormality, and somewhere around
0.5%-1.0% will have an intracerebral abnormality requiring neurosurgery.
Armed with this knowledge that a large number of normal scans will be
required to
detect those with significant intracerebral pathology..... it is up to
the clinician to decide which test is appropriate. In my humble opinion,
radiology and radiologists have no place in deciding what investigation is
appropriate in this setting. We are the clinicians, experienced in the
assessment of these patients.....In addition, the value of a normal scan is
that neurological observation is not required, the patient can go home
safely, and it's one less patient in the department to worry about.....I
would think that the only use for skull films in an institution where CT
head is readily available is in the infant paediatric population..... but
that is an entirely different argument.
----------------------
Just thought it was timely to raise this subject again. Saw a five month
old baby tonight, fell off bed onto stone floor. No LOC and well since.
However Mum worried as large parietal swelling rapidly developed. My exam
revealed very well baby and large parietal scalp haematoma. So I did a skull
film which showed a long parietal skull fracture. Admitted child under paeds
and discussed with our neurosurgeons. They felt a CT was not indicated,
partly as child very well and partly as a CT would probably require a GA or
sedation. In other words the CT might well lead to more problems than it
would solve, so simple observation was the lesser of two evils. Another
factor must be the radiation involved in head CT, which would be
considerable for an infant. Although it's difficult to be precise about
this, it cannot be discounted as a factor.
Do I presume this is what Paul Bailey meant by the use of skull films in
the paediatric population? Basically I felt the skull film was an ideal
investigation to stratify risk and direct management in this case. I can't
CT all well-babies who have temporoparietal swellings, but neither should I
admit them all for neuro-obs. A plain skull film neatly discriminates in
this situation.
Adrian Fogarty
