Re-examining the Brain Injury Guidelines in Pediatric Traumatic Brain Injury: Can Simple Isolated Non-Displaced Skull Fractures be Treated as a BIG-1 Injury?

Introduction: Children with mild traumatic brain injury (TBI) often receive unnecessary imaging studies, hospital admissions, and interhospital transfers leading to avoidable burdens to patients, caregivers, and health systems. The current Brain Injury Guidelines (BIG) consider a non-displaced skull fracture as a BIG-2 injury which warrants hospitalization. In our clinical experience, patients with simple isolated non-displaced linear skull fractures seldom develop TBI related complications. In this study, we evaluated the need for hospital admission for simple isolated linear skull fractures by examining the occurrence of clinically important TBI (ci-TBI) and patient outcome.

Methods: We performed a retrospective study evaluating pediatric TBI admissions using an institutional registry of TBI patients. We reviewed the medical records of patients under 17 years old to identify the presence of ci-TBI: ICI resulting in death or neurosurgical intervention due to a TBI. Patient outcome was evaluated with the Glasgow Outcome Score Extended (GOS-E) 6-months after injury. Univariable statistics were calculated for continuous variables and 95% confidence intervals were calculated using the Clopper-Pearson exact method for proportions that were very close to 0 or 1 and the Wilson score interval for small to moderate proportions.

Results: 804 subjects were analyzed. 402 (50.0%) patients had a BIG-2 injury, and in 247 (61.4%) of those patients, 198(80.2%) were transferred from referring hospitals. In both primary admissions and transfers, no significant injury progression on imaging was noted, no neurosurgical intervention occurred, and no patient had ci-TBI (0/247; 95% CI: 0% to 1.5%). 6-month GOS-E was available in a subset (53.8%) of patients: 98.5% were discharged home and had a favorable outcome (defined as GOS-E 5 to 7).

Conclusion : ci-TBI rarely develops in children with simple isolated non-displaced skull fractures. In the context of the current BIG, these patients can be considered for re-classification to a BIG-1 injury, which can reduce interhospital transfer and admission rates following implementation, while maintaining patient safety. A revised BIG classification for pediatric injuries is proposed.