Pediatric emergency medicine trisk 914
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patient is symptom free. Recent reports suggest that a return to activities 24
to 48 hours after physical rest, maintaining a level of activity that does not
cause symptom recurrence, may decrease the time to return to play. The
current consensus recommendations for return to play should follow a slow
progression with light aerobic exercise, advancing to sports-specific
exercise followed by noncontact drills and full-contact practice with final
advancement to full participation in all sporting activities. Other
recommendations to improve cognitive rest should include good sleep
hygiene, adequate hydration, and decreased use of electronic devices unless
necessary for school performance.
SKULL FRACTURES
CLINICAL PEARLS AND PITFALLS
Linear, parietal, nondepressed skull fractures are the most
common.
Skull fractures are common in accidental and nonaccidental
trauma.
Most linear, nondepressed skull fractures heal without
complications.
Goal of Treatment
The primary goal of treatment is to delineate simple, linear, nondepressed
skull fractures from complicated skull fractures. Complicated skull fractures
are more likely to be associated with intracranial injury and/or
nonaccidental trauma. Early injury pattern recognition and neurosurgical
consultation to determine need for surgical intervention is ideal.
FIGURE 113.3 Linear skull fracture. An axial CT scan with bone windows
demonstrates a closed linear nondisplaced skull fracture through the left orbital roof.
Current Evidence
Unilateral, linear skull fractures account for approximately 75% of pediatric
skull fractures ( Fig. 113.3 ). This estimate applies to both accidental and
nonaccidental pediatric skull fractures. The incidence of underlying
intracranial injury ranges from 15% to 30%. Complicated skull fractures
may include fractures that cross suture lines, complex, burst, depressed,
diastatic, bilateral, multiple, or open fractures. Figure 113.4 shows a closed,
depressed skull fracture. Complicated fractures have, not only an increased
likelihood of underlying intracranial injury, but also an increased
association with nonaccidental trauma. Of the complex fractures, ones that
cross suture lines, bilateral or multiple fractures were notably more
common in nonaccidental trauma. The complete description and evaluation
of abusive or nonaccidental head trauma is discussed separately in Chapter
87 Child Abuse/Assault .
FIGURE 113.4 Depressed skull fracture. An axial CT scan with bone windows
demonstrates a closed depressed skull fracture over the left parietal bone.
Clinical Considerations
Clinical Recognition
Many of the historical and physical findings suggestive of skull fracture are
the same as described above for ciTBI. The history may include a witnessed
fall, motor vehicle collision or assault. However, in many instances, there is
no accompanying history of a traumatic event. Many infants will present
with an isolated soft tissue swelling or scalp hematoma. Other presentations
may be nonspecific and include poor feeding, vomiting, irritability, a
bulging anterior fontanelle, altered mental status defined as a Pediatric
Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy,
seizure, presence of scalp hematoma, palpable skull defect or crepitus.
Typical complaints in children include headache, localized pain or soft
tissue swelling, vomiting, confusion, altered mental status defined as a GCS
of less than or equal to 14 ( Table 113.1 ), seizure, lethargy, focal
neurologic abnormality, obtundation, or signs of a basilar skull fracture (
Fig. 113.5 ).
The area of the skull most commonly involved is the parietal bone,
followed by the occipital and temporal bones. The physical examination
may be normal as soft tissue swelling may not be present at the time of
evaluation, or may include a scalp hematoma or soft tissue swelling,
palpable skull defect or crepitus. Signs of a basilar skull fracture ( Fig.
113.5 ) include Battle sign, periorbital ecchymosis, hemotympanum, and
CSF otorrhea or rhinorrhea. A full neurologic examination is mandated to
isolate any focal neurologic deficits. These focal deficits are related to the
underlying intracranial injury and allow for clinical detection of regional
lesions. The neurologic deficits frequently identified with basilar skull
fractures include anosmia, nystagmus, hearing loss (either conductive or
sensorineural), abducens nerve palsy, or facial paralysis.
Diagnostic Imaging. As previously discussed, skull radiography has a
limited role as it cannot provide details regarding intracranial injury. CT is
the preferred imaging modality for the initial evaluation as it allows for the
detection of fractures utilizing bone windows, especially with threedimensional reconstruction capability.
Ultrasonography has been shown to be sensitive for the detection of skull
fractures. It has limited capability to detect underlying intracranial injury
leading to a limited role in the initial evaluation of children with skull
fractures. It may be utilized emergently if there is no availability of CT to
assist in facilitating transfer to a pediatric trauma facility. Another future
application may be outpatient follow-up settings monitoring skull fractures,
