From the Guidelines
Yes, a 5-month-old with a parietal skull fracture should be evaluated by a neurosurgeon as soon as possible. Skull fractures in infants this young are concerning because their skulls are still developing and thin, making the brain more vulnerable to injury. The neurosurgeon will assess the type of fracture (linear, depressed, or comminuted), determine if there is any underlying brain injury, and evaluate whether surgical intervention is needed. Most linear fractures may heal without surgery, but depressed fractures might require surgical elevation. The child will likely need imaging studies such as a CT scan to fully evaluate the extent of the injury, as recommended by the American College of Radiology 1.
While waiting for the neurosurgical consultation, the infant should be closely monitored for signs of increased intracranial pressure, including excessive sleepiness, irritability, vomiting, seizures, or a bulging fontanelle. In infants this young, skull fractures also raise concerns about possible non-accidental trauma, so a thorough evaluation of the injury circumstances is standard practice. Early neurosurgical involvement is crucial for optimal outcomes in pediatric head injuries, and it is recommended that infants and children with traumatic head injuries be cared for by a pediatric neurosurgeon if one is within reasonable proximity 1.
The risk of significant injury in infants with skull fractures is substantial enough that imaging is strongly recommended, and CT has the advantage of rapid acquisition and excellent sensitivity for acute intracranial hemorrhage and fractures 1. The American Board of Pediatric Neurologic Surgery offers a subspecialty certificate in pediatric neurologic surgery, which recognizes training and experience in the care of children with neurologic surgical problems, and it is recommended that infants and children with neurosurgical problems be cared for by a pediatric neurosurgeon with access to other pediatric specialists 1.
Key considerations in the management of a 5-month-old with a parietal skull fracture include:
- Prompt evaluation by a neurosurgeon
- Imaging studies such as CT scan to evaluate the extent of the injury
- Close monitoring for signs of increased intracranial pressure
- Thorough evaluation of the injury circumstances to rule out non-accidental trauma
- Care by a pediatric neurosurgeon with access to other pediatric specialists.
From the Research
Evaluation Requirements for a 5-Month-Old with a Parietal Skull Fracture
- A 5-month-old with a parietal skull fracture may require evaluation by a neurosurgeon, especially if there are symptoms of neurologic dysfunction, neurologic compromise on examination, or a complicated skull fracture 2.
- The presence of a diastatic skull fracture with a width of at least 4 mm, CT demonstration of a cerebral contusion beneath the fracture, overlying scalp swelling, or a neurological abnormality contralateral to the fracture may warrant consideration of early surgery 3.
- Growing skull fracture (GSF) is a rare complication of cranial trauma in children younger than 3 years, characterized by a dural defect and herniation of the brain tissue, and may require neurosurgical reconstruction 4.
- While abusive head trauma (AHT) should be considered in the differential diagnosis of bilateral parietal skull fractures (BPSFs) in infants, these injuries can also occur as a result of accidental falls, and a thorough evaluation, including head imaging, skeletal survey X-rays, ophthalmology, and social work assessments, is necessary to determine the cause of the injury 5.
- A study of pediatric traumatic parietal skull fracture found that children with an intracranial lesion on CT scan were more likely to have symptoms of neurologic dysfunction, neurologic compromise on examination, or a complicated skull fracture, highlighting the importance of thorough evaluation and consideration of neurosurgical consultation in these cases 2, 6.