{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T11:15:19Z","timestamp":1780571719221,"version":"3.54.1"},"reference-count":40,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,4,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Pediatric head trauma is a common reason for emergency department (ED) referrals. Skull fractures are the most common imaging findings in the setting of pediatric trauma. Ample literature negates the necessity of hospitalization for neurologically intact children with isolated skull fractures (ISFs) and when nonaccidental injuries (NAIs) are not suspected. Despite this evidence, in many centers these children are still admitted for observation. The authors performed a retrospective analysis of the outcomes of children admitted with ISFs. A literature review of studies of children with ISFs was also performed. The objective of this study was to assess the necessity of admission of children with ISF.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A retrospective single-center analysis was performed, based on the electronic referral database of a tertiary pediatric hospital. Pediatric patients (< 18 years old) with a linear skull fracture on CT were included. Patients with additional traumatic intracranial findings on imaging (bleeding, pneumocephalus, edema, etc.) were excluded, as were patients with depressed, open, or displaced fractures. A systematic literature review of the Medline and PubMed databases was performed.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Two hundred fifty-eight children met the criteria between 2019 and 2022. Eighty-one percent sustained a fall. Other mechanisms of injury included blunt-force trauma and road accidents, and 10.5% had an unclear mechanism. Most children had parietal fractures (56.3%), followed by occipital fractures and others. Sixteen percent suffered from chronic illnesses. No cases of growing skull fractures were noted. None of the children needed neurosurgical intervention. Moreover, none needed a follow-up CT scan. Three patients were transferred from a first-tier hospital to the authors\u2019 institution, none because of neurosurgical concerns. Other than these 3 patients, all other children were admitted to a pediatric ward for 24-hour observation and subsequently discharged. NAI was highly suspected in 7.1% of children (3\/42) suffering from chronic illnesses as opposed to 1.4% (3\/216) of healthy children. This difference was not statistically significant (p = 0.056). The literature review yielded 680 papers. After screening for relevance, language, etc., 8 original series with 5823 patients remained. One patient (0.017%) was operated on, but probably not for ISF. The cost difference between discharge from the ED and admission ranged between $520 and $4291 (US dollars). None of the children discharged from the ED returned for hospitalization.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n In this original cohort, none of the children had a change in management following their admission. None needed neurosurgical intervention. In children with linear ISFs, a short ED observation should be considered, followed by discharge based on neurological status. A proposed ED discharge protocol is presented.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2024.11.peds24279","type":"journal-article","created":{"date-parts":[[2025,2,7]],"date-time":"2025-02-07T21:32:52Z","timestamp":1738963972000},"page":"400-406","source":"Crossref","is-referenced-by-count":2,"title":["Should pediatric patients with isolated skull fractures be admitted, transferred, or discharged from the emergency department, and what are the economic consequences? Original series, systematic review of the literature, and a proposed admission protocol"],"prefix":"10.3171","volume":"35","author":[{"given":"Ido","family":"Ben Zvi","sequence":"first","affiliation":[{"name":"Neurosurgery Department, Great Ormond Street Hospital for Children, London, United Kingdom; and"},{"name":"Neurosurgery Division, Schneider Children\u2019s Medical Center of Israel, Petah Tikva, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Galal","family":"Imtiaz","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Great Ormond Street Hospital for Children, London, United Kingdom; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rory J.","family":"Piper","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Great Ormond Street Hospital for Children, London, United Kingdom; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin M.","family":"Tisdall","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Great Ormond Street Hospital for Children, London, United Kingdom; and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"4","key":"b1","series-title":"Ann Emerg Med","first-page":"507","article-title":"Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms","volume":"42","author":"Haydel MJ","year":"2003","unstructured":"Haydel MJ, Shembekar AD. Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms. Ann Emerg Med. 2003;42(4):507\u2013514."},{"issue":"9","key":"b2","series-title":"Childs Nerv Syst","first-page":"1669","article-title":"Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF)","volume":"32","author":"Reuveni-Salzman A","year":"2016","unstructured":"Reuveni-Salzman A, Rosenthal G, Poznanski O, Shoshan Y, Benifla M. Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF). Childs Nerv Syst. 2016;32(9):1669\u20131674."},{"issue":"4","key":"b3","series-title":"Ann Emerg Med","first-page":"327","article-title":"Isolated skull fractures: trends in management in US pediatric emergency departments","volume":"62","author":"Mannix R","year":"2013","unstructured":"Mannix R, Monuteaux MC, Schutzman SA, Meehan WP III, Nigrovic LE, Neuman MI. Isolated skull fractures: trends in management in US pediatric emergency departments. Ann Emerg Med. 2013;62(4):327\u2013331."},{"issue":"5","key":"b4","series-title":"J Head Trauma Rehabil","first-page":"375","article-title":"The epidemiology and impact of traumatic brain injury: a brief overview","volume":"21","author":"Langlois JA","year":"2006","unstructured":"Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375\u2013378."},{"issue":"6","key":"b5","series-title":"J Neurosurg Pediatr","first-page":"703","article-title":"Linear nondisplaced skull fractures in children: who should be observed or admitted?","volume":"16","author":"Arrey EN","year":"2015","unstructured":"Arrey EN, Kerr ML, Fletcher S, Cox CS Jr, Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted?. J Neurosurg Pediatr. 2015;16(6):703\u2013708."},{"issue":"2","key":"b6","series-title":"J Neurosurg Pediatr","first-page":"205","article-title":"Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes","volume":"14","author":"Bonfield CM","year":"2014","unstructured":"Bonfield CM, Naran S, Adetayo OA, Pollack IF, Losee JE. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr. 2014;14(2):205\u2013211."},{"issue":"3","key":"b7","series-title":"Curr Opin Pediatr","first-page":"258","article-title":"Controversies in the evaluation and management of minor blunt head trauma in children","volume":"19","author":"Schnadower D","year":"2007","unstructured":"Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG. Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr. 2007;19(3):258\u2013264."},{"issue":"6","key":"b8","series-title":"Ann Emerg Med","first-page":"714","article-title":"A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children","volume":"71","author":"Bressan S","year":"2018","unstructured":"Bressan S, Marchetto L, Lyons TW, A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714\u2013724.e2."},{"issue":"5","key":"b9","series-title":"Pediatrics","first-page":"E11","article-title":"Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?","volume":"99","author":"Quayle KS","year":"1997","unstructured":"Quayle KS, Jaffe DM, Kuppermann N, Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?. Pediatrics. 1997;99(5):E11."},{"issue":"4","key":"b10","series-title":"Pediatrics","first-page":"e851","article-title":"Isolated linear skull fractures in children with blunt head trauma","volume":"135","author":"Powell EC","year":"2015","unstructured":"Powell EC, Atabaki SM, Wootton-Gorges S, Isolated linear skull fractures in children with blunt head trauma. Pediatrics. 2015;135(4):e851\u2013e857."},{"issue":"7","key":"b11","series-title":"J Pediatr Surg","first-page":"1342","article-title":"Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation","volume":"46","author":"Rollins MD","year":"2011","unstructured":"Rollins MD, Barnhart DC, Greenberg RA, Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg. 2011;46(7):1342\u20131346."},{"issue":"4","key":"b12","series-title":"J Pediatr Surg","first-page":"654","article-title":"Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly","volume":"51","author":"Blackwood BP","year":"2016","unstructured":"Blackwood BP, Bean JF, Sadecki-Lund C, Helenowski IB, Kabre R, Hunter CJ. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. J Pediatr Surg. 2016;51(4):654\u2013658."},{"issue":"1","key":"b13","series-title":"J Pediatr","first-page":"136","article-title":"Computed tomography for minor head injury: variation and trends in major United States pediatric emergency departments","volume":"160","author":"Mannix R","year":"2012","unstructured":"Mannix R, Meehan WP, Monuteaux MC, Bachur RG. Computed tomography for minor head injury: variation and trends in major United States pediatric emergency departments. J Pediatr. 2012;160(1):136\u2013139.e1."},{"issue":"5","key":"b14","series-title":"J Neurosurg Pediatr","first-page":"602","article-title":"Transfer of children with isolated linear skull fractures: is it worth the cost?","volume":"17","author":"White IK","year":"2016","unstructured":"White IK, Pestereva E, Shaikh KA, Fulkerson DH. Transfer of children with isolated linear skull fractures: is it worth the cost?. J Neurosurg Pediatr. 2016;17(5):602\u2013606."},{"issue":"9266","key":"b15","series-title":"Lancet","first-page":"1391","article-title":"The Canadian CT Head Rule for patients with minor head injury","volume":"357","author":"Stiell IG","year":"2001","unstructured":"Stiell IG, Wells GA, Vandemheen K, The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391\u20131396."},{"issue":"9696","key":"b16","series-title":"Lancet","first-page":"1160","article-title":"Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study","volume":"374","author":"Kuppermann N","year":"2009","unstructured":"Kuppermann N, Holmes JF, Dayan PS, Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160\u20131170."},{"issue":"4","key":"b17","series-title":"Pediatr Emerg Care","first-page":"301","article-title":"Management of isolated skull fractures in pediatric patients: a systematic review","volume":"35","author":"Donaldson K","year":"2019","unstructured":"Donaldson K, Li X, Sartorelli KH, Weimersheimer P, Durham SR. Management of isolated skull fractures in pediatric patients: a systematic review. Pediatr Emerg Care. 2019;35(4):301\u2013308."},{"issue":"2","key":"b18","series-title":"Pediatrics","first-page":"e247","article-title":"Skeletal surveys in infants with isolated skull fractures","volume":"123","author":"Wood JN","year":"2009","unstructured":"Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics. 2009;123(2):e247\u2013e252."},{"issue":"4","key":"b19","series-title":"Ann Emerg Med","first-page":"431","article-title":"Clinical presentations and outcomes of children with basilar skull fractures after blunt head trauma","volume":"68","author":"Tunik MG","year":"2016","unstructured":"Tunik MG, Powell EC, Mahajan P, Clinical presentations and outcomes of children with basilar skull fractures after blunt head trauma. Ann Emerg Med. 2016;68(4):431\u2013440.e1."},{"issue":"6","key":"b20","series-title":"Pediatr Emerg Care","first-page":"403","article-title":"Management of pediatric isolated skull fractures: a decision tree and cost analysis on emergency department disposition strategies","volume":"34","author":"Williams DC","year":"2018","unstructured":"Williams DC, Russell WS, Andrews AL, Simpson KN, Basco WT Jr, Teufel RJ II. Management of pediatric isolated skull fractures: a decision tree and cost analysis on emergency department disposition strategies. Pediatr Emerg Care. 2018;34(6):403\u2013408."},{"issue":"4","key":"b1","series-title":"Ann Emerg Med","first-page":"507","article-title":"Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms","volume":"42","author":"Haydel MJ","year":"2003","unstructured":"Haydel MJ, Shembekar AD. Prediction of intracranial injury in children aged five years and older with loss of consciousness after minor head injury due to nontrivial mechanisms. Ann Emerg Med. 2003;42(4):507\u2013514."},{"issue":"9","key":"b2","series-title":"Childs Nerv Syst","first-page":"1669","article-title":"Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF)","volume":"32","author":"Reuveni-Salzman A","year":"2016","unstructured":"Reuveni-Salzman A, Rosenthal G, Poznanski O, Shoshan Y, Benifla M. Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF). Childs Nerv Syst. 2016;32(9):1669\u20131674."},{"issue":"4","key":"b3","series-title":"Ann Emerg Med","first-page":"327","article-title":"Isolated skull fractures: trends in management in US pediatric emergency departments","volume":"62","author":"Mannix R","year":"2013","unstructured":"Mannix R, Monuteaux MC, Schutzman SA, Meehan WP III, Nigrovic LE, Neuman MI. Isolated skull fractures: trends in management in US pediatric emergency departments. Ann Emerg Med. 2013;62(4):327\u2013331."},{"issue":"5","key":"b4","series-title":"J Head Trauma Rehabil","first-page":"375","article-title":"The epidemiology and impact of traumatic brain injury: a brief overview","volume":"21","author":"Langlois JA","year":"2006","unstructured":"Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375\u2013378."},{"issue":"6","key":"b5","series-title":"J Neurosurg Pediatr","first-page":"703","article-title":"Linear nondisplaced skull fractures in children: who should be observed or admitted?","volume":"16","author":"Arrey EN","year":"2015","unstructured":"Arrey EN, Kerr ML, Fletcher S, Cox CS Jr, Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted?. J Neurosurg Pediatr. 2015;16(6):703\u2013708."},{"issue":"2","key":"b6","series-title":"J Neurosurg Pediatr","first-page":"205","article-title":"Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes","volume":"14","author":"Bonfield CM","year":"2014","unstructured":"Bonfield CM, Naran S, Adetayo OA, Pollack IF, Losee JE. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr. 2014;14(2):205\u2013211."},{"issue":"3","key":"b7","series-title":"Curr Opin Pediatr","first-page":"258","article-title":"Controversies in the evaluation and management of minor blunt head trauma in children","volume":"19","author":"Schnadower D","year":"2007","unstructured":"Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG. Controversies in the evaluation and management of minor blunt head trauma in children. Curr Opin Pediatr. 2007;19(3):258\u2013264."},{"issue":"6","key":"b8","series-title":"Ann Emerg Med","first-page":"714","article-title":"A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children","volume":"71","author":"Bressan S","year":"2018","unstructured":"Bressan S, Marchetto L, Lyons TW, A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714\u2013724.e2."},{"issue":"5","key":"b9","series-title":"Pediatrics","first-page":"E11","article-title":"Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?","volume":"99","author":"Quayle KS","year":"1997","unstructured":"Quayle KS, Jaffe DM, Kuppermann N, Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?. Pediatrics. 1997;99(5):E11."},{"issue":"4","key":"b10","series-title":"Pediatrics","first-page":"e851","article-title":"Isolated linear skull fractures in children with blunt head trauma","volume":"135","author":"Powell EC","year":"2015","unstructured":"Powell EC, Atabaki SM, Wootton-Gorges S, Isolated linear skull fractures in children with blunt head trauma. Pediatrics. 2015;135(4):e851\u2013e857."},{"issue":"7","key":"b11","series-title":"J Pediatr Surg","first-page":"1342","article-title":"Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation","volume":"46","author":"Rollins MD","year":"2011","unstructured":"Rollins MD, Barnhart DC, Greenberg RA, Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg. 2011;46(7):1342\u20131346."},{"issue":"4","key":"b12","series-title":"J Pediatr Surg","first-page":"654","article-title":"Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly","volume":"51","author":"Blackwood BP","year":"2016","unstructured":"Blackwood BP, Bean JF, Sadecki-Lund C, Helenowski IB, Kabre R, Hunter CJ. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. J Pediatr Surg. 2016;51(4):654\u2013658."},{"issue":"1","key":"b13","series-title":"J Pediatr","first-page":"136","article-title":"Computed tomography for minor head injury: variation and trends in major United States pediatric emergency departments","volume":"160","author":"Mannix R","year":"2012","unstructured":"Mannix R, Meehan WP, Monuteaux MC, Bachur RG. Computed tomography for minor head injury: variation and trends in major United States pediatric emergency departments. J Pediatr. 2012;160(1):136\u2013139.e1."},{"issue":"5","key":"b14","series-title":"J Neurosurg Pediatr","first-page":"602","article-title":"Transfer of children with isolated linear skull fractures: is it worth the cost?","volume":"17","author":"White IK","year":"2016","unstructured":"White IK, Pestereva E, Shaikh KA, Fulkerson DH. Transfer of children with isolated linear skull fractures: is it worth the cost?. J Neurosurg Pediatr. 2016;17(5):602\u2013606."},{"issue":"9266","key":"b15","series-title":"Lancet","first-page":"1391","article-title":"The Canadian CT Head Rule for patients with minor head injury","volume":"357","author":"Stiell IG","year":"2001","unstructured":"Stiell IG, Wells GA, Vandemheen K, The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391\u20131396."},{"issue":"9696","key":"b16","series-title":"Lancet","first-page":"1160","article-title":"Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study","volume":"374","author":"Kuppermann N","year":"2009","unstructured":"Kuppermann N, Holmes JF, Dayan PS, Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160\u20131170."},{"issue":"4","key":"b17","series-title":"Pediatr Emerg Care","first-page":"301","article-title":"Management of isolated skull fractures in pediatric patients: a systematic review","volume":"35","author":"Donaldson K","year":"2019","unstructured":"Donaldson K, Li X, Sartorelli KH, Weimersheimer P, Durham SR. Management of isolated skull fractures in pediatric patients: a systematic review. Pediatr Emerg Care. 2019;35(4):301\u2013308."},{"issue":"2","key":"b18","series-title":"Pediatrics","first-page":"e247","article-title":"Skeletal surveys in infants with isolated skull fractures","volume":"123","author":"Wood JN","year":"2009","unstructured":"Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics. 2009;123(2):e247\u2013e252."},{"issue":"4","key":"b19","series-title":"Ann Emerg Med","first-page":"431","article-title":"Clinical presentations and outcomes of children with basilar skull fractures after blunt head trauma","volume":"68","author":"Tunik MG","year":"2016","unstructured":"Tunik MG, Powell EC, Mahajan P, Clinical presentations and outcomes of children with basilar skull fractures after blunt head trauma. Ann Emerg Med. 2016;68(4):431\u2013440.e1."},{"issue":"6","key":"b20","series-title":"Pediatr Emerg Care","first-page":"403","article-title":"Management of pediatric isolated skull fractures: a decision tree and cost analysis on emergency department disposition strategies","volume":"34","author":"Williams DC","year":"2018","unstructured":"Williams DC, Russell WS, Andrews AL, Simpson KN, Basco WT Jr, Teufel RJ II. Management of pediatric isolated skull fractures: a decision tree and cost analysis on emergency department disposition strategies. Pediatr Emerg Care. 2018;34(6):403\u2013408."}],"container-title":["Journal of Neurosurgery: Pediatrics"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-pediatr\/35\/4\/article-p400.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-pediatr\/35\/4\/article-p400.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-pediatr\/35\/4\/article-p400.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T13:46:35Z","timestamp":1772804795000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-pediatr\/35\/4\/article-p400.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,1]]},"references-count":40,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.3171\/2024.11.peds24279","relation":{},"ISSN":["1933-0707","1933-0715"],"issn-type":[{"value":"1933-0707","type":"print"},{"value":"1933-0715","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,4,1]]}}}