Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case.

BACKGROUND: After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home. OBSERVATIONS: Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection. LESSONS: In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

Validation of the Surgical Intervention for Traumatic Injury scale in the pediatric population.

OBJECTIVE: While the Glasgow Coma Scale (GCS) has been effective in describing severity in traumatic brain injury (TBI), there is no current method for communicating the possible need for surgical intervention. This study utilizes a recently developed scoring system, the Surgical Intervention for Traumatic Injury (SITI) scale, which was developed to efficiently communicate the potential need for surgical decompression in adult patients with TBI. The objective of this study was to apply the SITI scale to a pediatric population to provide a tool to increase communication of possible surgical urgency. METHODS: The SITI scale uses both radiographic and clinical findings, including the GCS score on presentation, pupillary examination, and CT findings. To examine the scale in pediatric TBI, a neurotrauma database at a level 1 pediatric trauma center was retrospectively evaluated, and the SITI score for all patients with an admission diagnosis of TBI between 2010 and 2015 was calculated. The primary endpoint was operative intervention, defined as a craniotomy or craniectomy for decompression, performed within the first 24 hours of admission. RESULTS: A total of 1524 patients met inclusion criteria for the study during the 5-year span: 1469 (96.4%) were managed nonoperatively and 55 (3.6%) patients underwent emergent operative intervention. The mean SITI score was 4.98 ± 0.31 for patients undergoing surgical intervention and 0.41 ± 0.02 for patients treated nonoperatively (p < 0.0001). The area under the receiver operating characteristic (AUROC) curve was used to examine the diagnostic accuracy of the SITI scale in this pediatric population and was found to be 0.98. Further evaluation of patients presenting with moderate to severe TBI revealed a mean SITI score of 5.51 ± 0.31 in 40 (15.3%) operative patients and 1.55 ± 0.02 in 221 (84.7%) nonoperative patients, with an AUROC curve of 0.95. CONCLUSIONS: The SITI scale was designed to be a simple, objective communication tool regarding the potential need for surgical decompression after TBI. Application of this scale to a pediatric population reveals that the score correlated with the perceived need for emergent surgical intervention, further suggesting its potential utility in clinical practice.