When Its Just a Bump on the Head: Interpreting Skull Fractures in the Context of Child Maltreatment
There is currently no consensus about which screening studies should be undertaken to identify abusive injuries in infants with apparently isolated skull fractures.
- Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.
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To say there is variation in how medical providers evaluate and workup children with isolated skull fractures would be an understatement. Just to reiterate, when there are additional injuries or findings that are concerning for abuse, then a full workup with skeletal survey and appropriate labs is warranted. But when there is an isolated skull fracture without other concerns, there is a lot of debate about whether to do additional workup. What I usually ask is what is the pre-test probability for abuse in this case with an isolated skull fracture, and does it reach the threshold for pursuing an abuse workup? If the pre-test probability is low, what is the possibility of a false-positive or indeterminate finding on the skeletal survey that will lead to further testing and intervention?
