How should a 5-year-old with a small depressed skull area after head trauma be evaluated and managed?

Management of a 5-Year-Old with Small Skull Depression After Head Injury

A 5-year-old with a palpable skull depression after head trauma requires immediate non-contrast head CT to evaluate for underlying skull fracture and intracranial injury, as physical examination findings of skull deformity are highly specific (99%) for fracture and strongly predictive of complications requiring intervention. 1

Immediate Evaluation

Clinical Assessment Priority

• Obtain non-contrast head CT immediately when skull depression is palpable on examination, as this finding has a likelihood ratio of 16 and 99% specificity for skull fracture 1
• Head CT is superior to skull radiographs because it simultaneously detects both the fracture and any associated intracranial complications (hemorrhage, edema, midline shift) that skull X-rays cannot visualize 2
• Skull radiographs should not be used as they have only 63% sensitivity for detecting skull fractures and provide no information about intracranial injury 2

Neurological Examination Details

• Document Glasgow Coma Scale score (any score <15 increases risk significantly) 1, 3
• Assess pupillary size and reactivity bilaterally 3
• Check for focal neurological deficits 1
• Evaluate mental status for any alteration, confusion, or drowsiness 1

Critical Historical Features to Obtain

• Mechanism of injury (fall from >1 meter height increases suspicion) 1
• Presence of loss of consciousness 4
• Number of vomiting episodes (≥2 episodes has likelihood ratio of 3.6 for intracranial injury) 1
• Duration of any amnesia (>30 minutes is concerning) 1
• Time elapsed since injury 5

Imaging Strategy

Why CT is Mandatory

• The American College of Radiology states that CT is the appropriate diagnostic modality when skull fracture is suspected based on clinical examination 1, 3
• CT provides rapid acquisition without sedation requirement and excellent sensitivity for acute hemorrhage and fractures 4
• Do not use MRI acutely as it requires longer acquisition times, often needs sedation, and is not recommended for routine acute evaluation 2

What CT Will Reveal

• Presence and type of skull fracture (linear, depressed, complex) 6
• Associated intracranial hemorrhage (epidural or subdural hematoma occurs in 40% of pediatric skull fractures) 5
• Brain edema or contusion 2
• Midline shift 2

Risk Stratification Based on Findings

High-Risk Features Requiring Neurosurgical Consultation

• GCS score ≤14 1, 3
• Any decline in GCS score from initial assessment 1
• Depressed skull fracture with underlying intracranial injury 6
• Epidural or subdural hematoma 5, 6

Observation Requirements

• If CT shows isolated skull fracture without intracranial injury: minimum 4-6 hours of ED observation with serial neurological examinations every 30-60 minutes 4
• Monitor specifically for GCS motor response, pupillary changes, and level of alertness 4
• Repeat CT only if clinical deterioration occurs (≥2 point GCS decrease or new focal deficit) 4

Management Pathway

If CT Shows Depressed Fracture with Intracranial Injury

• Immediate neurosurgical consultation 6
• Hospital admission for neurological monitoring 5, 6
• Serial neurological examinations 4

If CT Shows Isolated Depressed Fracture Without Intracranial Complications

• Neurosurgical evaluation to determine if surgical elevation is needed 6
• Most children with minor head trauma and skull fracture achieve full recovery without surgical intervention 5, 6
• In one pediatric series, 56% required neurosurgical procedures, but 99% achieved good outcomes 6

Special Consideration for Age

• The pediatric skull has remarkable remodeling capacity—even profound skull deformities can remodel nearly completely within 6 months in young children 7
• However, this does not eliminate the need for acute evaluation, as the concern is underlying brain injury, not cosmetic deformity 1

Post-Discharge Management (If Admitted and Stabilized)

Activity Restrictions

• Complete physical and cognitive rest for 24-48 hours 4
• No school, screen time, reading, or vigorous activity during initial rest period 4
• Do not allow return to contact sports, physical education, or high-risk playground activities until completely asymptomatic and cleared by physician 4

Return Precautions for Parents

• Seek immediate medical attention for: persistent or worsening vomiting, increasing drowsiness, seizures, worsening headache, unsteady walking, or behavior changes 4
• Schedule follow-up with primary care physician within 24-48 hours 4

Gradual Return to Activities

• After initial 24-48 hour rest, begin light activities as tolerated, stopping immediately if symptoms recur 4
• Progress to 30-60 minutes of quiet cognitive activity once asymptomatic at rest 4
• Advance to half-day school with accommodations before full-day attendance 4

Critical Pitfalls to Avoid

Do Not Rely on Skull X-Rays

• Skull radiographs miss intracranial injuries entirely and have poor sensitivity for fractures 2
• The presence of a palpable depression mandates CT, not plain films 1

Do Not Delay Imaging in Delayed Presentations

• Even if the child presents days after injury with progressive scalp swelling, CT is still indicated to rule out underlying fracture and intracranial complications 5
• In one series of children presenting >24 hours after injury with scalp swelling, 40% had skull fractures with associated extra-axial hemorrhage 5

Do Not Assume Benign Course Without Imaging

• While most children with minor head trauma recover fully, intracranial complications can occur even without skull fracture (29% of subdural hematomas and 17% of epidural hematomas occurred without fracture in one series) 6
• A palpable skull depression is a high-risk physical finding that cannot be managed conservatively without imaging 1