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INTRODUCTION

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Traumatic brain injury is a leading cause of death and disability in children. In the United States, approximately 3000 children and adolescents (0 to 16 years of age) die from traumatic brain injury each year. There are approximately 400,000 hospital emergency department visits and 29,000 hospitalizations each year for pediatric head trauma.1–4

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SKULL FRACTURE

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Linear Skull Fracture

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About three-quarters of skull fractures in children are linear. Approximately 75% of these fractures occur in the parietal bones, 15% in the occipital bones, and 5% in the frontal bones. Most linear skull fractures do not cross sutures (Figure 21-1); extension across a suture usually indicates a high force injury, such as a motor vehicle incident or child abuse. Traumatic suture separation (diastases) is a rare form of a linear skull fracture. An isolated, linear, nondiastatic skull fracture most often occurs without accompanying brain injury. A small venous epidural hematoma is the most common intracranial sequela. A subperiosteal hematoma is a common extracranial complication of a skull fracture. Identification of a crescentic subperiosteal hematoma is an important clue on axial CT images for an underlying fracture.2

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Figure 21–1

Linear skull fracture.

A lateral radiograph of a 18-month-old child shows a linear parietal skull fracture (arrows). The fracture stops at the coronal suture.

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Depressed Skull Fracture

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A depressed skull fracture involves displacement of the injured portion of the skull intracranially. These fractures sometimes require surgical intervention. Many depressed skull fractures are compound; brain injury is more common in association with compound depressed skull fractures than with simple fractures. Depressed fractures are more frequent in older children than in infants. Common mechanisms include a fall (40%), motor vehicle incident (20%), and birth injury (15%).Most often, the mechanism involves a focal blow or other application of force to the head.5

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A ping-pong ball fracture is a depressed fracture that is unique to newborns and young infants. There is indentation of a portion of the thin pliable skull, without discontinuity of the bone (Figure 21-2). A true depressed fracture has a break of the inner or outer cortical table and inward displacement of 1 edge of the bone relative to the other, but without displacement of an isolated fragment (Figure 21-3). The flat depressed fracture refers to displacement of one or more separated fragments of bone intracranially (Figure 21-4); this is the least common of the depressed skull fractures. CT provides the most accurate characterization of depressed skull fractures. This allows quantification of diastasis and depression, as well as the detection of intracranial hemorrhage, brain injury, pneumocephalus, extracranial complications, and foreign material (Figure 21-5). Accumulation of low attenuation fluid in the region of the fracture suggests the presence ...

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