PREDICTIVE VALUE OF SKULL RADIOGRAPHY FOR INTRACRANIAL INJURY IN CHILDREN WITH BLUNT HEAD-INJURY

Background The value of routine skull radiography as a method of predi cting intracranial injury is controversial. We aimed to assess the eff ectiveness of skull radiography by prospectively studying head-injured children admitted to a children's hospital that serves an urban popul ation. Methods Over a 2-year period, 9269 children attended our accide nt and emergency department with head injury, and 6011 were referred f or skull radiography. All children who were admitted to hospital or ha d a skull fracture (n=883) were included in the study. Computed tomogr aphy (CT) was done in children with skull fractures on radiography and in those without fractures if there were neurological indications. Fi ndings Radiographs showed 162 fractures (2.7% of all radiographs and 1 8% of study group radiographs). Staff in the accident and emergency de partment missed 37 (23%) fractures. CT scan was done on 156 children, of whom 107 had a skull fracture. 23 children were found to have intra cranial injuries on CT. The presence of neurological abnormalities had a sensitivity for identification of intracranial injury of 91% (21 of 23) and a negative predictive value of 97%. The corresponding values for skull fracture on radiography were 65% (15 of 23) and 83%. Four ch ildren died, of whom only one had a skull fracture. Interpretation In children, severe intracranial injury can occur in the absence of skull fracture. Skull radiography is not a reliable predictor of intracrani al injury and is indicated only to confirm or exclude a suspected depr essed fracture or penetrating injury, and when non-accidental injury i s suspected, including in all infants younger than 2 years. Clinical n eurological abnormalities are a reliable predictor of intracranial inj ury. If imaging is required, it should be with CT and not skull radiog raphy.