Gravel et al reported a clinical decision rule for identifying a young child with a skull fracture after isolated head trauma. The rule can help to reduce the number of imaging studies performed. The authors are from the University of Montreal, Montreal Children's Hospital, University of Sherbrooke, and McGill University.

Patient selection: isolated head trauma, age < 2 years, not at high risk for traumatic brain injury (all of GCS=15, no palpable skull fracture, normal level of consciousness)


High risk for traumatic brain injury - one or more of the following: GCS < 15, altered level of consciousness, or palpable skull fracture.


Predictors for a skull fracture:

(1) age < 2 months

(2) parietal or occipital hematoma


In the study population of 811, 6% had a skull fracture.

Of 94 patients with a hematoma, 40% had a skull fracture.

Of 56 patients less than 2 months old and without a hematoma, 14% had a skull fracture.

Of the remaining patients only 0.5% had a skull fracture (3 out of 661).

Overall the sensitivity ranged from 0.89-0.94 with a specificity of 0.86.


To detect more cases the age predictor could be changed to <= 3 months. This would give the rule a sensitivity of 98% and specificity of 82%.

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