Radiography in young children with minor head injuries

A new decision rule will help emergency department physicians determine when to use radiography in young children with minor head injuries. The Canadian-developed rule is published in the Canadian Medical Association Journal.

There is no consensus on how to treat children with head injury who do not meet the criteria for Computed tomography (CT) imaging but may still be at risk of complications.

To fill this gap, researchers developed and tested a rule to help emergency department physicians identify children aged younger than 2 years who are at risk. This was a 2-phase project. In the first phase, they included 811 patients, of whom 49 had skull fractures, to develop the decision tool. In the second phase, they confirmed the validity of the tool in a new group of 856 patients, of whom 44 had skull fractures. Using the decision tool, the researchers identified approximately 90% of skull fractures in children with minor head injuries.

“The 2 predictors identified through recursive partitioning for the development of the rule were parietal or occipital swelling or hematoma and age less than 2 months,” wrote Jocelyn Gravel, MD, Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Quebec, and colleagues. “Use of the rule would have decreased the overall number of skull radiographs by about 60% in our study population.”...

In an accompanying commentary, Peter Gill, MD, The Hospital for Sick Children (SickKids) and University of Toronto, Toronto, Ontario, and Terry Klassen, MD, University of Manitoba, Winnipeg, Manitoba, wrote: “The authors provide front-line clinicians with objective decision-making criteria, more helpful than 'observation versus CT. But perhaps most important, the rule is simple: in children aged less than 2 years with a minor head injury who do not meet the criteria for a CT scan, perform a skull radiograph if they are less than 2 months old or they have parietal or occipital swelling. If only all clinical decision rules could be this simple.”

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Gravel J, Gouin S, Chalut D, Crevier L, Décarie JC, Elhazary N, Masse B.
Derivation and validation of a clinical decision rule to identify young children
with skull fracture following isolated head trauma. CMAJ. 2015 Sep 8. pii:
cmaj.150540. [Epub ahead of print]

Abstract

BACKGROUND:

There is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography.

METHODS:

We performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score < 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning.

RESULTS:

A total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%-99%) and a specificity of 86% (95% CI 84%-89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase.

INTERPRETATION:

The clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%.