Is a skull X-ray (radiograph) indicated for a child who has experienced a fall?

Skull X-Ray for Falls in Children: Not Recommended

Skull radiographs should NOT be routinely used for children who have experienced a fall, as they are insufficient to evaluate for intracranial injury and do not reliably predict clinically important traumatic brain injury. 1

Primary Imaging Approach Based on Clinical Risk

The decision to image depends on clinical assessment, not routine skull X-rays:

High-Risk Children (Require Immediate CT Head)

• Glasgow Coma Scale ≤13 (moderate to severe head trauma) 1
• Altered mental status or decreased level of consciousness 2, 3
• Focal neurological deficits 4, 2
• Signs of basilar skull fracture (hemotympanum, Battle's sign, raccoon eyes) 4
• Suspected depressed or penetrating skull fracture on clinical examination 2

Intermediate-Risk Children (Clinical Observation ± CT)

• Loss of consciousness at time of injury 4
• Persistent vomiting 5
• Severe mechanism of injury 5
• Palpable skull abnormality 5

These children should be hospitalized for 48-hour clinical observation without routine skull X-rays 4

Low-Risk Children (Discharge with Head Injury Instructions)

• Asymptomatic with normal neurological examination 4, 5
• No loss of consciousness 4
• Normal behavior and activity 5

Why Skull X-Rays Are Not Indicated

The evidence against routine skull radiography is compelling:

• Poor sensitivity for intracranial injury: 60% of children with epidural hematoma, 85% with subdural hematoma, and 35% with brain damage have NO skull fracture 4
• Low predictive value: Skull fracture on X-ray has only 65% sensitivity for intracranial injury with 83% negative predictive value, compared to 91% sensitivity and 97% negative predictive value for clinical neurological abnormalities 2
• Cannot detect intracranial pathology: Skull X-rays show only bone and cannot visualize hemorrhage, edema, or brain injury 1, 4
• Up to 50% of intracranial injuries occur without skull fracture 1

Special Circumstances Where Skull X-Ray May Be Considered

Suspected Non-Accidental Trauma (Child Abuse)

This is the primary indication for skull X-rays in modern pediatric practice:

• All infants 0-11 months with skull fractures should have skeletal survey (which includes skull films) to evaluate for abuse 1
• Exception: Infants 7-11 months with linear, unilateral skull fracture from witnessed high-height fall may not require full skeletal survey 1
• Complex or "ping-pong" skull fractures always warrant skeletal survey regardless of age 1
• Skull X-rays are part of the skeletal survey protocol when evaluating for multiple fractures and abuse patterns 1

Infants Under 2 Years

• The CDC guideline states skull radiographs should not be used for screening intracranial injury even in this age group 1
• However, if skull fracture is clinically suspected and CT is not immediately indicated, skull X-ray may help determine need for CT and neurosurgical consultation 5
• Clinical suspicion for skull fracture is itself a risk factor for intracranial injury in young children 1

The Correct Imaging Algorithm

When imaging IS clinically indicated:

1. CT head without contrast is the appropriate initial study for acute evaluation 1, 3

   • Rapid acquisition
   • Excellent sensitivity for hemorrhage, herniation, and fractures requiring intervention
   • Can detect both intracranial injury AND skull fractures simultaneously

2. MRI head is reserved for:

   • Subacute presentations (8 days to 1 month post-injury) with persistent symptoms 1
   • When CT is negative but neurological deficits persist 1
   • Non-emergent evaluation of suspected abusive head trauma 1

Critical Pitfalls to Avoid

• Do not be falsely reassured by normal skull X-rays - severe intracranial injury frequently occurs without fracture 4, 2
• Do not use skull X-rays to "rule out" significant injury - clinical examination is more predictive than skull films 2, 3
• Do not delay CT when clinically indicated by obtaining skull X-rays first 3
• Emergency department staff miss 23% of skull fractures on X-ray, further limiting utility 2

Cost and Radiation Considerations

Eliminating routine skull X-rays can reduce approximately 2,000 unnecessary radiographs per year in a typical pediatric emergency department without increasing missed injuries or hospital admissions 4. Children under 5 years are at higher risk from radiation exposure, making the avoidance of unnecessary imaging particularly important 4.