Palpable signs of skull fractures on physical examination and depressed skull fractures or traumatic brain injuries on CT in children

To assess the actual presence of underlying depressed skull fractures and traumatic brain injuries (TBI) on computed tomography (CT) in children with and without palpable skull fractures on physical examination following minor head trauma. This was a secondary analysis of a prospective, observational multicenter study enrolling 42,412 children < 18 years old with Glasgow Coma Scale scores >= 14 following blunt head trauma. A palpable skull fracture was defined per the treating clinician documentation on the case report form. Skull fractures and TBIs were determined on CT scan by site radiologists. Palpable skull fractures were reported in 368/10,698 (3.4%) children < 2 years old, and in 676/31,613 (2.1%) of older children. Depressed skull fractures on CT were observed in 56/273 (20.5%) of younger children with palpable skull fractures and in 34/3047 (1.1%) of those without (rate difference 19.4%; 95%CI 14.6-24.2%), and in 30/486 (6.2%) vs 63/11,130 (0.6%) of older children (rate difference 5.6%; 95%CI 3.5-7.8%). TBIs on CT were found in 73/273 (26.7%) and 189/3047 (6.2%) of younger children with and without palpable skull fractures (rate difference 20.5%; 95%CI 15.2-25.9), and in 61/486 (12.6%) vs 424/11,130 (3.8%) of older children (rate difference 8.7%; 95%CI 6.1-12.0). Conclusions: Although depressed skull fractures and TBIs on CT are more common in children with palpable fractures than those without, most of these children do not have underlying depressed fractures. The discriminatory ability of the scalp examination could be enhanced by direct bedside visualization of the skull, such as through ultrasound.