Accuracy of the Physical Examination for Pediatric Skull Fracture
Date First Published:
January 12, 2024
Last Updated:
January 12, 2024
Report by:
Ryan Pitney MD, Melisa Gagrica MD, EM senior resident, EM faculty (Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI)
Search checked by:
Jeffrey S. Jones MD, Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI
Three-Part Question:
What is the [accuracy of the physical examination] to [identify skull fractures] in [pediatric patients presenting to the ED]?
Clinical Scenario:
A 5-year-old female presents to the emergency department after a fall from playground equipment. Parents are concerned about significant head injury. You perform history and physical exam and would like to use a pediatric head injury algorithm to help guide your need for advanced imaging and you hope to avoid unneeded imaging. You wonder how accurate your exam is for pediatric skull fracture.
Search Strategy:
Medline 1966-01/24 using PubMed, Cochrane Library (2024), and Embase
Search Details:
[Skull fractures diagnosis AND physical examination]
Outcome:
44 studies were identified; 3 studies addressed the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomogr Akie TE, Gupta M, Rodriguez RM, Hendey GW, Wilson JL, Quinones AK, Mower WR. Mar-23 USA | 1,018 pediatric patients with head injury; 81 with skull fractures | Retrospective observation study | Sensitivity of provider physical examination to detect skull fractures | 18.5% (95% confidence interval 10.5% to 28.7%) | Retrospective secondary analysis of a previously collected database of pediatric patients presenting with a blunt head injury. All participants had to have a CT head obtained at the index visit (verification bias). CT images were not independently reviewed or determined by consensus, which may have resulted in the incorrect assignment of injuries. Numbers of depressed and basilar skull fractures were low. |
| Specificity of provider physical examination to detect skull fractures | 96.6% (95% CI 95.3% to 97.1%) | ||||
| Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma. Tunik MG, Powell EC, Mahajan P, Schunk JE, Jacobs E, Miskin M, Zuspan SJ, Wootton-Gorges S, Atabaki SM, Hoyle JD Jr, Holmes JF Jr, Dayan PS, Kuppermann N; Pediatric Emergency Care Applied Research Net Oct-16 USA | 43,399 pediatric patients with blunt head trauma occurring within 24 hours before ED evaluation | Observational cohort study (secondary analysis) | Physical examination findings suggestive of basilar skull fractures | CT showed basilar skull fracture in 28.7% of patients with examination findings | CT scans were not performed on all children; some patients with basilar skull fractures may therefore have been missed. Some of the equivocal CT interpretations were interpreted as normal results. There was no set definition of physical examination signs of basilar skull fractures. Long-term adverse events were not identified in follow-up. |
| Adverse outcomes in patients with isolated basilar skull fracture and normal neurologic examinations | 0% (95% CI 0% to 1.4%) | ||||
| Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma Gravel J, Gouin S, Chalut D, Crevier L, Décarie JC, Elazhary N, Mâsse B. Nov-15 Canada | A total of 1667 children less than 2 years old who had head trauma (93 with skull fracture) | Prospective cohort study in 3 tertiary care emergency departments | Sensitivity of clinical decision rule to detect skull fracture | 89% (95% CI 76%–95%) | Not all of the patients had a radiologic evaluation; study took place in tertiary care settings (selection bias); interrater reliability was not measured[ small number of children with skull fractures; the clinical decision rule was validated in the same sites as those used in the derivation phase; and the decision rule was not used by the treating physicians in the validation phase. |
| Specificity of clinical decision rule to detect skull fracture | 87% (95% CI 84%–89%) |
Author Commentary:
The accuracy of a physical exam in detecting skull fractures in older children can vary, and it is influenced by factors such as the experience and expertise of the healthcare provider, the type of fracture, and the presence of other symptoms. In general, studies suggest that physical exams alone may not be sufficient to diagnose all skull fractures, especially if the fracture is not accompanied by noticeable external signs. In children less than 2 years old who had acute head trauma, a clinical decision rule (parietal or occipital swelling or hematoma and age less than 2 months) identified about 90% of skull fractures. However, this rule has not been externally validated.
Bottom Line:
Clinician physical exam is poorly sensitive for skull fracture in pediatric patients presenting to the ED with blunt head trauma.
References:
- Akie TE, Gupta M, Rodriguez RM, Hendey GW, Wilson JL, Quinones AK, Mower WR. . Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomogr
- Tunik MG, Powell EC, Mahajan P, Schunk JE, Jacobs E, Miskin M, Zuspan SJ, Wootton-Gorges S, Atabaki SM, Hoyle JD Jr, Holmes JF Jr, Dayan PS, Kuppermann N; Pediatric Emergency Care Applied Research Net. Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.
- Gravel J, Gouin S, Chalut D, Crevier L, Décarie JC, Elazhary N, Mâsse B. . Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma