CT is all you need for some pediatric skull fractures

CT with 3D reconstruction is more than sufficient for diagnosing skull fractures in young children with abusive head trauma, according to a study published in Pediatric Radiology.

When a child arrives at the emergency room with a trauma injury, the possibility of child abuse is an unfortunate reality. A clear description of how the injury happened can set clinicians’ minds at ease, but a muddled account and lack of bystanders can raise suspicions, according to Child Abuse Pediatric Fellow Paige Culotta, MD, at Texas Children’s Hospital.

“There are some factors that are more concerning, especially if it’s an event that’s not witnessed,” she said. “If someone’s in a crowded area and adults see the accident then we know it happened, but If the story doesn’t make sense or if there is no story, then our doctors will have more concern.”

If doctors are worried about abuse, they order a full skeletal survey including a skull x-ray. However, x-ray typically preforms poorly in diagnosing intracranial hemorrhaging or other soft-tissue injuries, making a head CT scan a necessity.

The catch? With 3D reconstruction, doctors can diagnose fractures on CT, in addition to any internal injury.

“One of our radiologists, James Crowe, asked why we even do the skull films at all—they weren’t giving us any new information,” said Culotta.

Crowe, a contributing author on the study, wanted to eliminate the skull x-rays from the workflow. To determine if they were less sensitive than the CT exams, the team conducted a retrospective study of 177 infants evaluated for non-accidental head injuries via both skull x-rays and CT.

They found no loss in diagnostic yield when performing only the CT scan, as the CT scan can correctly diagnose both fractures and intracranial injury with high sensitivity. CT offered a number of advantages over x-rays, including the ability for non-specialists to reliably interpret images.

“Even skilled pediatric radiologists can have difficulty making accurate interpretations from skull radiographs, especially in cases where a full clinical history is not provided,” wrote the authors.

By using CT instead, a radiology department can give pediatricians, emergency physicians or even trainees a better ability to read images without the help of a radiology subspecialist.

In addition, eliminating the skull x-ray gives clinicians the same diagnostic ability while reducing radiation exposure to a child who may have abusive head trauma.

“In cases where there is a concern for head trauma and clinicians require CT scans to adequately access intracranial injury, skull radiographs should be eliminated from the medical work-up,” wrote the authors. “This approach would spare children additional radiation and potentially decrease false-positive findings without compromising reliable findings.”