Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 399-406
World Neurosurgery

Original Article
Reappraisal of Pediatric Diastatic Skull Fractures in the 3-Dimensional CT Era: Clinical Characteristics and Comparison of Diagnostic Accuracy of Simple Skull X-Ray, 2-Dimensional CT, and 3-Dimensional CT

https://doi.org/10.1016/j.wneu.2017.08.107Get rights and content

Background

Diastatic skull fractures (DSFs) in children are difficult to detect in skull radiographs before they develop into growing skull fractures; therefore, little information is available on this topic. However, recent advances in 3-dimensional (3D) computed tomography (CT) imaging technology have enabled more accurate diagnoses of almost all forms of skull fracture. The present study was undertaken to document the clinical characteristics of DSFs in children and to determine whether 3D CT enhances diagnostic accuracy.

Methods

Two hundred and ninety-two children younger than 12 years with skull fractures underwent simple skull radiography, 2-dimensional (2D) CT, and 3DCT. Results were compared with respect to fracture type, location, associated lesions, and accuracy of diagnosis.

Results

DSFs were diagnosed in 44 (15.7%) of children with skull fractures. Twenty-two patients had DSFs only, and the other 22 had DSFs combined with compound or mixed skull fractures. The most common fracture locations were the occipitomastoid (25%) and lambdoid (15.9%). Accompanying lesions consisted of subgaleal hemorrhages (42/44), epidural hemorrhages (32/44), pneumocephalus (17/44), and subdural hemorrhages (3/44). A total of 17 surgical procedures were performed on 15 of the 44 patients. Fourteen and 19 patients were confirmed to have DSFs by skull radiography and 2D CT, respectively, but 3D CT detected DSFs in 43 of the 44 children (P < 0.001).

Conclusion

3D CT was found to be markedly superior to skull radiography or 2D CT for detecting DSFs. This finding indicates that 3D CT should be used routinely rather than 2D CT for the assessment of pediatric head trauma.

Introduction

Skull fractures are one of the most common trauma injuries among children, comprising 2%–16% of all head injuries and 11% of injuries in children younger than 2 years.1, 2, 3 Approximately 15%–50% of skull fractures are associated with intracranial injuries, such as intracranial hemorrhage, contusion, cerebrospinal fluid leakage, or vessel injury, and 40%–100% of intracranial injuries in children are accompanied by cranial fractures.1, 4, 5 Hence, it has been suggested that skull fractures in children are associated with significant mortality and morbidity resulting from intracranial injury, and that accurate diagnosis is critical.6

Diastatic skull fractures (DSFs) involve the suture line either partially or wholly, and they are more frequently encountered in children than in adults.7 In the past, DSFs have been diagnosed in children with simple skull radiography, but because sutural ossification is incomplete in children, physiologic diastasis can make the diagnosis of DSF problematic.7, 8 Because of these diagnostic difficulties, many authors have stressed the clinical importance of accompanied growing skull fractures that increased the DSF diagnostic rate in children. Without growing skull fractures, little information regarding DSFs is available in the literature regarding the prevalence, associated intracranial injuries, and clinical course, along with older diagnostic methods such as simple skull radiography.9, 10, 11

Recent technological advances in 3-dimensional (3D) computed tomography (CT) have led to the use of 3D CT rather than, or in combination with or instead of, 2-dimensional (2D) CT or simple skull radiography for the evaluation of all cranial fractures for all ages, especially for children because 3D CT can provide more accurate assessment of linear skull fractures.4, 6, 12, 13 However, literature on the use of 3D CT for the diagnosis of DSF is limited to a single report by Kim et al.,8 who described 15 cases of DSF. Somewhat surprisingly, no clinical reports have addressed this subject to date. We retrospectively studied the relationship between the clinical characteristics of 44 children with DSF and simple skull radiography, 2D CT, and 3D CT findings. In addition, we compared the diagnostic accuracies of 3D CT, simple skull radiography, 2D CT, and simple skull radiography plus 2DCT.

Section snippets

Study Population

Simple skull radiography, 2D CT, and 3D CT for 347 pediatric patients younger than 12 years who visited our institute for head trauma during the 9-year period from May 1, 2005, to April 30, 2014, were examined retrospectively. Of the 347 patients, 292 had various types of skull fractures as follows: linear fracture in 191 patients (65.41%), diastatic fractures in 22 patients (7.53%), depression fractures in 21 patients (7.19%), basal skull fractures in 5 patients (1.71%), burst fractures in 2

Incidence and Clinical Characteristics of DSF

For the 292 children with cranial fractures, DSF was diagnosed in 44 of them (15.7%). Of these 44 patients, 31 were male, and the mean overall age was 64.4 ± 37.3 months. Eleven patients had a simple DSF, 11 patients had multiple DSFs, and the remaining 22 patients had DSFs plus multiple compound fractures (Figure 1, Figure 2, Figure 3). The most common location of DSFs was the occipitomastoid suture (20/44) followed by the lambdoid suture (15/44; Table 2).

The most common lesions associated

Incidence, Demography, and Location of DSF

DSF has been described as the separation of cranial sutures as a result of external trauma.7 The diagnosis of DSF in pediatric patients should be arrived at cautiously, because widening of a suture line does not always imply the presence of a fracture; it may simply be a normal variation.13, 14, 15, 16, 17 The diagnosis of a cranial fracture in pediatric patients entails consideration of sociomedical values because confirmation of external trauma can lead to legal issues or charges of child

Conclusion

3D CT was significantly more accurate at diagnosing pediatric head trauma DSF than was simple skull radiography or 2D CT. DSF in children with cranial fractures was 15.7% in incidence, with a high association of multiple or compound fractures, intracranial complications, and higher surgery rates.

Acknowledgment

We are grateful to Dr. Chang K.H. for preparing the English-version manuscript.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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