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How Accurate Is Physical Exam for Pediatric Skull Fracture?

December 8, 2022

Written by Clay Smith

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Physical exam for pediatric skull fracture has poor sensitivity. Avoid overconfidence in exam as a screening tool.

Why does this matter?
Detecting skull fracture is part of PECARN criteria and other decision rules to determine which patients to scan, but how accurate is physical exam for skull fracture as a screening test?

Avoid overconfidence
This was a planned reanalysis of the NEXUS II Head CT study. 1,108 pediatric patients with head injuries who were undergoing CT were included, with 128 having significant injuries on CT; 85 (66.4%) of these had skull fractures as well. Providers in the original study prospectively documented their findings using either NEXUS or Canadian head CT rules. Sensitivity of physical exam was just 18.5% for detecting skull fracture; specificity was 96.6%. From other studies, just 58% of patients with basilar skull fracture had hemotympanum, and Battle’s sign was also very rarely, if ever, seen. So, it seems that when providers were ordering CT, other clinical features must have been driving the decision. My take home points: 1) Skull fractures are common among head injured children but are hard to find or may not be present on exam; avoid overconfidence in my exam skills. 2) If I think there is a skull fracture, I am probably right, and a CT is warranted.

Physical Examination Sensitivity for Skull Fracture in Pediatric Patients with Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomography Validation Study. Ann Emerg Med. 2022 Oct 31;S0196-0644(22)01031-9. doi: 10.1016/j.annemergmed.2022.08.442. Online ahead of print.

What are your thoughts?