Follow up of infants with skull fractures by neurosurgeons due to the risk of growing fractures; is it needed?

Introduction: Growing skull fractures are a rare complication of paediatric skull fractures. Despite its rarity, a large proportion of resources go towards detecting this complication. This study aims to identify the factors associated with growing skull fracture development to determine which children require follow-up.

Materials and methods: This was a single-centre retrospective study examining the referral data from all patients under one years old referred with head trauma between 2013 and 2023 (n = 246). Of these patients 189 sustained skull fractures, with two requiring surgery for a growing skull fracture. Referral data for all head injuries between 2008 and 2013 was unavailable but surgical records were accessed for the only case of a child who developed a growing skull fracture in this time period. Each fracture was analysed using the commuted tomography (CT) head for its characteristics, including fracture splay distance and fracture elevation/depression.

Results: A total of 190 cases were reviewed, which showed a male to female ratio of 1.6:1. The majority of patients presented prior to one month of age and the most common mechanism of injury was a fall (80%). The most common fracture sustained was a linear fracture (87.4%). Of all fractures, the most common bone affected was the parietal bone (88.4%). Of those who developed a growing skull fracture, there was a significant difference in both the fracture splay distance (p < .05) and fracture elevation/depression distance (p < .05). All three patients who had growing skull fractures had a fracture splay distance above 5 mm at presentation and an elevation/depression of over 4 mm. 32% of children (n = 61) who had fractures had follow-up, with only nine having a fracture diastasis over 4mm.

Conclusion: Resources and investigations should focus on children with fracture displacement over 4mm and/or elevation/depression distance of over 3mm, as they are at significantly greater risk of growing skull fracture development.