What are the implications and necessary steps for a 7-year-old boy with a skull X-ray showing a fissure?

Skull X-Ray Showing a Fissure in a 7-Year-Old Boy

Skull radiographs should not be used to diagnose or manage pediatric head trauma, as they have only 63% sensitivity for detecting skull fractures, cannot identify intracranial injuries, and provide no information about brain parenchyma—if clinical concern exists for intracranial injury, obtain a head CT instead. 1

Why Skull X-Rays Are Inadequate

The finding of a "fissure" (likely representing a skull fracture) on skull radiography is of limited clinical utility for several critical reasons:

• Skull radiographs miss up to 50% of intracranial injuries that occur without associated fractures 2, 3
• Radiographs cannot detect intracranial complications such as hemorrhage, midline shift, or cerebral edema—the injuries that actually determine morbidity and mortality 1
• 60% of children with epidural hematomas, 85% with subdural hematomas, and 35% with brain damage have no skull fracture on imaging 4
• The presence of an isolated skull fracture without neurological abnormalities rarely warrants intervention 4

Immediate Next Steps

If this child has ANY high-risk features, obtain a non-contrast head CT immediately:

High-Risk Features Requiring Immediate CT 2, 5:

• Glasgow Coma Scale (GCS) ≤14 or any altered mental status (4.3% risk of clinically important injury)
• Signs of basilar skull fracture (hemotympanum, Battle's sign, raccoon eyes, CSF otorrhea/rhinorrhea)
• Post-traumatic seizure
• Focal neurological deficits

Intermediate-Risk Features—Consider CT vs. Observation 2, 5:

• History of loss of consciousness
• Severe or worsening headache
• Persistent vomiting (≥2 episodes)
• Severe mechanism of injury (high-speed motor vehicle accident, fall from significant height)

Very Low-Risk—No CT Needed 2, 5:

• GCS = 15 with completely normal mental status
• No loss of consciousness (or ≤5 seconds in children <2 years)
• No signs of basilar skull fracture
• No vomiting or only single episode
• No severe headache
• Acting normally per parents
• No severe injury mechanism

Critical Management Algorithm

1. Perform thorough neurological examination focusing on mental status, GCS score, pupillary response, focal deficits, and signs of basilar skull fracture 2, 5

2. If high-risk features present: Obtain immediate non-contrast head CT using pediatric-specific, reduced-dose protocols 2

3. If intermediate-risk features present: Either obtain CT or admit for 24-48 hours of clinical observation with serial neurological examinations 2, 5

4. If very low-risk: Discharge home with detailed head injury instructions and reliable caregiver to monitor for concerning symptoms 5

Important Caveats

• Consider non-accidental trauma in any child with unexplained injuries, inconsistent history, or delayed presentation—these cases require different evaluation protocols including skeletal survey and may warrant CT or MRI regardless of standard criteria 2, 6

• Clinical observation is effective: Every additional hour of emergency department observation decreases CT utilization without delaying diagnosis of significant traumatic brain injury 2

• Do not be falsely reassured by normal skull radiographs—clinical examination is paramount, and severe intracranial injury can occur without skull fracture 4, 3

Monitoring Instructions for Discharge

If the child meets very low-risk criteria and is discharged, provide written instructions to return immediately for 5:

• Persistent or worsening vomiting
• Increasing drowsiness or difficulty arousing
• Seizure activity
• Worsening or severe headache
• New neurological symptoms (weakness, vision changes, unsteady gait)
• Behavioral changes or irritability
• Unequal pupil size