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Ann Emerg Med. 2018 Jun;71(6):714-724.e2. doi: 10.1016/j.annemergmed.2017.10.014. Epub 2017 Nov 24.

A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children.

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Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy. Electronic address:
Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy.
Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.



Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim is to quantify the frequency of short-term adverse outcomes of children with isolated skull fractures.


PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and gray literature were systematically searched to identify studies reporting on short-term adverse outcomes of children aged 18 years or younger with linear, nondisplaced, isolated skull fractures (ie, without traumatic intracranial injury on neuroimaging). Two investigators independently reviewed identified articles for inclusion, assessed quality, and extracted relevant data. Our primary outcome was emergency neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeated neuroimaging. Meta-analyses of pooled estimate of each outcome were conducted with random-effects models, and heterogeneity across studies was assessed.


Of the 587 studies screened, the 21 that met our inclusion criteria included 6,646 children with isolated skull fractures. One child needed emergency neurosurgery and no children died (pooled estimate 0.0%; 95% confidence interval [CI] 0.0% to 0.0%; I2=0%). Of the 6,280 children with known emergency department disposition, 4,914 (83%; 95% CI 71% to 92%; I2=99%) were hospitalized. Of the 569 children who underwent repeated neuroimaging, 6 had new evidence of intracranial hemorrhage (0.0%; 95% CI 0.0% to 9.0%; I2=77%); none required operative intervention.


Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns.

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