For a 2‑year‑old with an open, non‑depressed frontal bone fracture and a frontal intracranial hematoma who is minimally confused, should I admit for neuro‑observation instead of initiating prophylactic antiepileptic medication?

Management of 2-Year-Old with Open Frontal Bone Fracture and Intracranial Hematoma

Admit this child for neuro-observation and do NOT initiate prophylactic antiepileptic medication. The presence of minimal confusion (altered mental status) places this patient in the high-risk category requiring immediate CT imaging and hospital admission, but prophylactic antiepileptics are not indicated for open, non-depressed skull fractures without seizure activity. 1, 2, 3

Risk Stratification Mandates Admission

This child meets high-risk PECARN criteria due to altered mental status (minimal confusion), which carries a 4.3% risk of clinically important traumatic brain injury and mandates both immediate CT and hospital admission. 1, 2

• Any altered mental status—including confusion, agitation, somnolence, or repetitive questioning—automatically elevates a pediatric head trauma patient to high-risk status regardless of other factors. 1, 2
• The presence of an intracranial hematoma on imaging further confirms the need for inpatient neuro-observation to monitor for clinical deterioration, expanding hematoma, or increased intracranial pressure. 1, 4
• More than one-third of patients with frontal bone fractures have concomitant intracranial injury, and 8-10% require surgical evacuation of subdural or epidural hematoma. 1, 4

Surgical Considerations for the Open Fracture

The open (compound) frontal bone fracture requires surgical evaluation, but immediate operative intervention is NOT mandatory because the fracture is non-depressed. 3

• Open depressed cranial fractures greater than the thickness of the cranium (typically >1 cm depression) require operative intervention to prevent infection. 3
• However, open non-depressed fractures may be managed nonoperatively if there is no dural penetration, significant intracranial hematoma requiring evacuation, frontal sinus involvement, gross contamination, or pneumocephalus. 3
• All open fractures require antibiotic prophylaxis regardless of whether surgery is performed. 3
• Neurosurgery consultation should be obtained immediately given the combination of open fracture and intracranial hemorrhage. 4

Prophylactic Antiepileptics Are NOT Indicated

Do not initiate prophylactic antiepileptic medication in this patient. There is no evidence supporting prophylactic antiepileptics for open, non-depressed skull fractures with intracranial hematoma in the absence of seizure activity.

• Post-traumatic seizure is a high-risk feature that would mandate immediate CT and potentially warrant antiepileptic therapy, but this patient has not seized. 1, 2
• The guidelines focus on identifying patients who require imaging and observation, not on prophylactic seizure management for non-depressed fractures. 1, 2, 3

Observation Protocol During Admission

Admit to a monitored unit with serial neurological examinations every 2-4 hours for at least 24 hours. 2, 5

• Monitor for signs of clinical deterioration including worsening mental status, new focal neurological deficits, persistent vomiting, severe or worsening headache, or signs of increased intracranial pressure. 1, 2
• Repeat head CT is indicated if any neurological deterioration occurs during observation. 2
• The mean hospital stay for admitted pediatric skull fracture patients is approximately 46 hours, though many require longer stays when Child Protective Services involvement or additional injuries are present. 5

Critical Imaging Already Obtained

The initial non-contrast head CT has already identified the frontal bone fracture and intracranial hematoma; ensure maxillofacial CT with thin sections was also performed to fully characterize the fracture. 1

• Multidetector CT with thin-section acquisitions and multiplanar reconstructions is essential for detecting subtle non-displaced fractures and characterizing complex injuries. 1
• Frontal bone fractures commonly involve the frontal sinus, and injuries to the nasofrontal duct can lead to mucocele formation or osteomyelitis. 1
• Cervical spine imaging should be considered given that 6-19% of patients with significant maxillofacial trauma have associated cervical spine injuries. 1

Common Pitfalls to Avoid

• Do not discharge this patient home—altered mental status is an absolute indication for admission regardless of how "minimal" the confusion appears. 1, 2
• Do not rely on skull radiographs, as they miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 2, 6
• Do not delay neurosurgical consultation when intracranial hemorrhage is present, as life-threatening complications take precedence over fracture repair. 4
• Consider non-accidental trauma in any young child with unexplained injuries, inconsistent history, or delayed presentation—this may require skeletal survey and different evaluation protocols. 1, 6