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fall, motor vehicle collision or assault. However, in many instances, there is
no accompanying history of a traumatic event. Many infants will present
with an isolated soft tissue swelling or scalp hematoma. Other presentations
may be nonspecific and include poor feeding, vomiting, irritability, a
bulging anterior fontanelle, altered mental status defined as a Pediatric
Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy,
seizure, presence of scalp hematoma, palpable skull defect or crepitus.
Typical complaints in children include headache, localized pain or soft
tissue swelling, vomiting, confusion, altered mental status defined as a GCS
of less than or equal to 14 ( Table 113.1 ), seizure, lethargy, focal
neurologic abnormality, obtundation, or signs of a basilar skull fracture (
Fig. 113.5 ).
The area of the skull most commonly involved is the parietal bone,
followed by the occipital and temporal bones. The physical examination
may be normal as soft tissue swelling may not be present at the time of
evaluation, or may include a scalp hematoma or soft tissue swelling,
palpable skull defect or crepitus. Signs of a basilar skull fracture ( Fig.
113.5 ) include Battle sign, periorbital ecchymosis, hemotympanum, and
CSF otorrhea or rhinorrhea. A full neurologic examination is mandated to
isolate any focal neurologic deficits. These focal deficits are related to the
underlying intracranial injury and allow for clinical detection of regional
lesions. The neurologic deficits frequently identified with basilar skull
fractures include anosmia, nystagmus, hearing loss (either conductive or
sensorineural), abducens nerve palsy, or facial paralysis.
Diagnostic Imaging. As previously discussed, skull radiography has a
limited role as it cannot provide details regarding intracranial injury. CT is
the preferred imaging modality for the initial evaluation as it allows for the
detection of fractures utilizing bone windows, especially with threedimensional reconstruction capability.
Ultrasonography has been shown to be sensitive for the detection of skull
fractures. It has limited capability to detect underlying intracranial injury
leading to a limited role in the initial evaluation of children with skull

fractures. It may be utilized emergently if there is no availability of CT to
assist in facilitating transfer to a pediatric trauma facility. Another future
application may be outpatient follow-up settings monitoring skull fractures,