Article Text

G249(P) is that skull fracture NAI? In the under 2 years
  1. C Bevan1,2,
  2. L Perera1,
  3. E Johns2
  1. 1Childrens Emergency Department, Royal Alexandra Childrens Hospital, Brighton, UK
  2. 2Brighton and Sussex Medical School, Brighton University, Brighton, UK


Aims To evaluate the safeguarding assessment of “Under 2s” presenting to a Children’s Emergency Department (CED) with suspected skull fracture.

Methods A retrospective study between the 1st January 2012 to 1st January 2015 for children under 2 years old who underwent radiological investigation (CT or XRAY Head) for acute head injury.

Results 52 patients underwent investigation (CT head/skull x-ray) the average age was 6 months.

Of these development was assessed in 40% of cases and a full body examination was documented in 67%.

22 (42%) had confirmed skull fractures (SF), with an average age of 7 months (4.6–9.5 months).

Most fractures (78%) were simple, linear and parietal. 21/22 cases (95%) presented with localised head swelling, bruising or haematoma and the most common mechanisms were: fall 74%, unexplained 13% and accidentally dropped 9%. 65% were discussed with social services.

10/22 (45%) underwent skeletal survey (SS), with additional fractures (rib fractures) detected in 1 child.12/22 did not have a SS of whom half were under 6 months age.

Overall 7/52 (13%) were on social service plans at time of presentation.

All children who underwent skeletal survey had a strategy meeting. Only 2/52 (4%) cases were defined as definitive NAI, only one had a skull fracture.

All skull fractures were admitted. 2 children were transferred to neurosurgical centres for close observation (small subdural bleed) neither were defined as NAI.

Conclusion It was interesting to note the small number of SS performed in the less than 6 months age group, which on notes review appeared to be attributed to the clinicians assessment of low likelihood of NAI in that individual patient.

From this limited study the presence of a skull fracture did not help predict the likelihood of NAI. The diagnosis of NAI relies on a multiagency approach; there is no gold-standard for diagnosis. This is the first UK study looking at this population of children. There is no validated decision making tool for this population of children with skull fractures to aid inclusion/exclusion of non-accidental injury. A multicentre study would allow larger numbers to draw conclusions with regards to decision making.

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