Head X-Ray is NOT Appropriate for Head Injury Evaluation
Skull radiographs (X-rays) have been replaced by CT scanning and should not be used in the initial imaging evaluation of head trauma. 1
Why Skull X-Rays Are Inadequate
Skull radiographs are not sufficient to evaluate for traumatic injury because up to 50% of intracranial injuries in children occur in the absence of fracture, and not all skull fractures are evident by radiographs 1
There is no relevant literature to support the use of radiographs in the initial imaging evaluation of acute head trauma, as CT is more sensitive for neurosurgical lesions (hemorrhage, herniation, hydrocephalus) 1
Clinical observation with or without skull X-rays is inadequate to rule out potentially dangerous intracranial lesions in apparently mild head injuries 2
The Correct Imaging Approach: CT Scanning
For Mild Head Injury (GCS 13-15)
Noncontrast head CT is usually appropriate when imaging is indicated by clinical decision rules 1
CT should be obtained if ANY of the following risk factors are present:
- Loss of consciousness or post-traumatic amnesia 1
- Headache 1, 3, 4
- Vomiting 1, 3, 4
- Age over 60 years 1, 3
- Physical evidence of trauma above the clavicles 1, 3
- Post-traumatic seizure 1
- GCS score <15 1
- Focal neurologic deficit 1
- Coagulopathy or anticoagulant use 1
- Drug or alcohol intoxication 3, 4
- Dangerous mechanism of injury (ejection from vehicle, pedestrian struck, fall >3 feet or 5 stairs) 1
For Moderate (GCS 9-12) or Severe (GCS 3-8) Head Injury
Noncontrast head CT is always appropriate and should be obtained immediately 1
Key Clinical Context
Over 75% of acute head trauma is classified as mild, yet only 10% or less will have positive CT findings, and only 1% or less require neurosurgical intervention 1
All patients with positive CT scans in validation studies had at least one of the clinical risk factors listed above, demonstrating 100% sensitivity (95% CI: 95-100%) for the clinical decision rules 3
In patients with maxillofacial trauma, concurrent intracranial injuries are common (68% of patients with facial fractures have associated head injuries), making CT of both the head and maxillofacial region usually required 5
Critical Pitfall to Avoid
Never rely on skull X-rays to "rule out" significant head injury before deciding whether to obtain a CT scan. The presence or absence of skull fracture on X-ray does not reliably predict intracranial injury—23 of 58 patients requiring surgery for intracranial lesions had no skull fractures 2. Go directly to CT when clinical criteria are met.