Uncomplicated linear skull fractures in the paediatric population: a retrospective observational study in a UK Major Trauma Centre

Purpose: National Institute of Clinical Excellence (NICE) guidelines advise that paediatric patients with linear skull fractures do not require admission in the absence of intracranial injury. Despite this, a period of inpatient neuro-observation has become the standard advice and practice in the UK for fear of deterioration. Our experience is that these children rarely deteriorate or require neurosurgical intervention. The primary aim of this study was to describe the incidence of neurological deterioration in patients referred to our paediatric neurosurgery unit with linear skull fractures.

Methods: We identified all patients with a linear skull fracture referred to neurosurgery at a paediatric major trauma centre between 2018 and 2023. Patients with intracranial injury, skull base fracture or major trauma were excluded. Demographic and clinical data were collected. The primary outcome was deterioration which was defined as drop in Glasgow Coma Scale (GCS) score, unplanned repeat cranial imaging, neurosurgical intervention performed, or the patient died.

Results: Two hundred and ninety-four patients were identified in our referral database. Infants were the age group most commonly referred (44.2%) and falls from under 2 m in height the most common mechanism of injury (71.4%). Ninety-seven children had specific advice documented regarding neuro-observation; of these, the majority (n = 53) were advised 24 hours of inpatient observation. No patients experienced deterioration.

Conclusions: This is the largest cohort of linear skull fractures in children described in the UK. None of our patients experienced neurological deterioration, mirroring findings from international studies and supporting current NICE guidance. In addition, at a cost of £360 per 24-hour admission, this has a cost implication for a resource-scarce NHS. We propose that UK trauma networks should devise protocols to support the safe discharge from ED of such patients without the need for discussion with a neurosurgical department.