Utility of Head Computed Tomography in Children with aSingle Extremity Fracture

Paria Majd Wilson, MD1, Michael Chua, MD2, Marguerite Care, MD3, Mary V. Greiner, MD4, Brooks Keeshin, MD4,

and Berkeley Bennett, MD, MS2

Objectives To determine the clinical and forensic utility of head computed tomography (CT) in children youngerthan 2 years of age with an acute isolated extremity fracture and an otherwise-negative skeletal survey.Study design Retrospective chart review of children younger than 2 years of age who obtained a skeletal surveyin the Cincinnati Children’s Hospital Medical Center Emergency Department during the 159-month study period.Clinically important head injury was determined based on previously defined Pediatric Emergency Care AppliedResearch Network criteria. Forensically significant head injury was defined as that which increased the concernfor inflicted injury. The rate of head CT relative to patient age and location of fracture (proximal vs distal extremity,upper vs lower extremity) was determined via c2 tests.Results Of the 320 children evaluated, 37% received neuroimaging, 95.7% of which had no signs of skull fractureor intracranial trauma. Five children (4.3%)with head imaging had traumatic findings but no children in the study hadclinically significant head injury. Three of these children had previous concerns for nonaccidental trauma and find-ings on head CT that were forensically significant. There was a greater rate of head imaging in children in theyounger age groups and those with proximal extremity fractures (P < .05).Conclusions In young children who present with an isolated extremity fracture, clinicians should consider obtain-ing head CT in those who are younger than 12 months of age, have proximal extremity fractures, or who haveprevious evaluations for nonaccidental trauma. Evaluation with head CT in children without these risk factorsmay be low yield. (J Pediatr 2014;164:1274-9).

See editorial, p 1250 andrelated article, p 1268

ntracranial injury (ICI) associated with nonaccidental trauma (NAT) is an important cause of morbidity and mortality in

Iyoung children. Although life-threatening injuries can be clinically obvious, more subtle injuries may be difficult to identifybecause accurate histories often are lacking and the neurologic assessment of young children can be challenging.1-3 Although

the American Academy of Pediatrics recommends that skeletal surveys be obtained in all children younger than 2 years of agewith concerns for abuse, there is a paucity of literature to guide clinicians as to when it is appropriate to obtain head imaging toscreen for occult ICI.4

The absence of guidelines to aid in screening for occult ICI in children with suspected physical abuse has led investigators topropose management guidelines for different risk stratifications.5,6 Early studies, such as that published by Quayle et al,7 statethat a clinician should consider obtaining a head computed tomography (CT) in children with a history of head injury whopresent with signs of altered mental status, signs of basilar skull fracture, focal neurologic deficits, or seizures. Unfortunately,the presence of these clinical findings do not always correlate with head CT findings.8

Rubin et al9 recommended head imaging for children younger than 6 months of age, children with rib fractures, multiplefractures, or facial injury. Laskey et al10 found similar findings to Rubin, reporting that 29% of neurologically asymptomaticpatients in their study population were found to have occult ICI, and recommended younger than 1 year of age as a marker forobtaining neuroimaging.

In a systematic review of children younger than 18 years of age, Maguire et al11 demonstrated that a statistically significantassociation did not exist between long bone fractures and inflicted brain injury, possibly related to the differing biomechanics ofthese injuries. Previous studies have cited rates of occult ICI ranging from 29%10 to 37%.9 On the basis of our collective clinical

From the 1Pediatric Emergency Medicine Fellow,2Division of Emergency Medicine, 3Department ofRadiology, and 4Mayerson Center for Safe and HealthyChildren, Cincinnati Children’s Hospital Medical Center,Cincinnati, OH

The authors declare no conflicts of interest.

0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All

rights reserved.

http://dx.doi.org/10.1016/j.jpeds.2013.12.041

CML Classic metaphyseal lesion

CT Computed tomography

ED Emergency department

ICI Intracranial injury

NAT Nonaccidental trauma

PECARN Pediatric Emergency Care Applied Research Network

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Vol. 164, No. 6 � June 2014

experiences, we hypothesized that less than 25% of childrenwith an isolated extremity fracture would have clinicallyand/or forensically significant ICI on head CT.

The purpose of this study was to determine the utility ofhead CT in children younger than 2 years of age with an acuteisolated extremity fracture and an otherwise-negative skeletalsurvey. The goals were to provide descriptive analysis of thispopulation, determine the clinical and forensic significanceof CT findings, and to determine whether unnecessary radi-ation can be reduced in this specific population.

Methods

We performed a retrospective review of all children youngerthan 2 years of age who obtained a skeletal survey in theCincinnati Children’s Hospital Medical Center EmergencyDepartment (ED) during a 159-month period fromSeptember 20, 1998 through November 30, 2011. Institu-tional review board approval was obtained prior to studycommencement, and informed consent was waived by theinstitutional review board.

Eligible subjects included children younger than 2 years ofage with an isolated extremity fracture who received a skeletalsurvey for further evaluation. We selected this populationbecause in our practice we had frequently been faced withthe uncertainties of when to obtain imaging in well appearingchildren with isolated extremity fractures and were curious tosee whether intracranial findings were found frequently inthis population. An isolated appendicular skeletal fracturewas defined as a single fracture in one extremity or isolatedfractures of radius and ulna or tibia and fibula in a single ex-tremity. We also included children with documented signs ofpain in an extremity and an associated periosteal reaction inthe underlying bone concerning for possible fracture.

Patients were excluded if they had fractures of the axialskeleton or skull. Children without obvious concerns forbony injury who had skeletal surveys obtained for an abuseevaluation or abnormal bruising patterns were excludedbecause these findings would influence clinicians to obtainhead CTs, regardless of the fracture. We also excluded chil-dren with metabolic bone disease or congenital disordersthat increased the potential for bone fragility. In the eventthat an acute fracture was noted in addition to a healing frac-ture or an additional questionable fracture, the patient wasconsidered greater risk and excluded from the study. Chil-dren with head CTs obtained before their skeletal surveywere excluded (determined based on the time stamp as docu-mented in the electronic medical record). Children withclassic metaphyseal lesions (CMLs) also were excludedbecause CMLs have been shown to be strongly associatedwith inflicted ICI. A single pediatric radiologist (M.C.) re-viewed all skeletal survey reports with equivocal findings(or periosteal reactions) to determine study eligibility.

A medical record review was performed by the first andsecond authors. Charts were identified through a query ofelectronic medical records for children younger than 2 years

of age who had obtained a skeletal survey. If the chiefcomplaint stated on the radiology record by the physicianincluded concern for an extremity fracture, the patient wasincluded in the study. If none of the exclusion criteria weremet, the patient remained in the study, and the results ofthe head CT (if performed) were recorded. The medical re-cords of patients who did not have a head CT completed dur-ing the same evaluation as the skeletal survey were reviewedto see whether neuroimaging was obtained within 7 days afterthe initial presentation to determine whether there were anycases of missed acute head injury in this group.12 For childrenwith signs of ICI on head CT, the medical records also werereviewed for documentation by social work and/or the childabuse team regarding concerns for abuse.Our institution does not have an established institutional

practice protocol for abuse and relies on the most up todate American Academy of Pediatrics guidelines for imagingrecommendations. Skeletal surveys were obtained accordingto the American College of Radiology Practice Guidelines.Each survey consisted of a systematic series of at least 19 ra-diographs. A tightly collimated frontal view of each individ-ual extremity was obtained. Images of the axial skeletonincluded anterior-to-posterior radiographs of the thoraxand skull, an anterior-to-posterior view of the pelvis, and alateral view of the cervical, thoracic, and lumbar spine. Obli-que rib radiographs and additional views to clarify question-able findings were added at the discretion of the interpretingradiologist. The head CT imaging protocol included contig-uous axial 5-mm images through the brain. Images wereviewed in both standard and bone algorithm. Notably, in2009, coronal standard reconstructions of the brain werealso added to the routine trauma head CT protocol.13

OutcomesFindings on head CT were classified as traumatic and non-traumatic, with the latter category further broken downinto intracranial and extracranial findings. Head CTs wereconsidered positive for trauma if there was evidence of skullfracture or traumatic intracranial findings, including but notlimited to intraparenchymal hemorrhage, extra-axial hemor-rhage, mass effect, or cerebral edema. Soft-tissue swelling inthe absence of skull fracture or ICI was not considered tobe positive in this investigation. Clinically important headinjury was determined on the basis of previously used Pedi-atric Emergency Care Applied Research Network (PECARN)criteria5,14 and included death from traumatic brain injury,neurosurgery, intubation for more than 24 hours for trau-matic brain injury, or hospital admission of 2 nights ormore associated with traumatic brain injury. Forensically sig-nificant head injury was defined as that which increased theconcern for inflicted injury as documented by hospital socialworkers or the child abuse team.

CovariatesAdditional factors studied included patient age and locationof fracture (proximal vs distal extremity, upper vs lower

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THE JOURNAL OF PEDIATRICS � www.jpeds.com Vol. 164, No. 6

extremity). Subjects were divided into 4 age groups: 0-3months, 4-6 months, 7-12 months, and 13-24 months. Theages were chosen to represent developmental changes andincreased mobility in older infants (rolling in 4-6 monthsand cruising in 7-12 months) and toddlers (walking) that in-crease the risk for accidental injury. Proximal fractures weredefined as injuries to the humerus or femur. Distal fractureswere defined as injuries to the radius, ulna, tibia, or fibula.

Statistical AnalysesDescriptive statistics were calculated to determine the percent-age of children who also had concomitant head injury on headCT. Frequencies were calculated for categorical variables. Forunivariate analyses, we used the Pearson c2 test to evaluatethe association between head imaging and relevant covariates.The goodness of fit test was performed to test the null hypoth-esis that the true percent of trauma cases was equal to the truepercent of non-trauma cases identified byCT scan (p0 = 50%).A P-value of < .05 was considered to be statistically significantin all analyses. Analyses were performed using SAS, version 9.3(SAS Institute, Cary, North Carolina).

Results

During the study period, 3653 children younger than 2 yearsof age received skeletal surveys, 320 of which were childrenwho had skeletal surveys obtained due to concerns of isolatedextremity fractures. The mean age of patients was 9.1 � 6months, with a range of 0-24 months. The mean age of thosewho received head CT was 7.0 � 5.4 months.

TheFiguredemonstrates the breakdownof the 117 children(36.6%)who obtained head imaging. Eleven of the 117 (9.4%)

Figure. Breakdown of patients involved in study.

1276

patients with head imaging had positive findings, which werefurther categorized as traumatic and nontraumatic. Findingsnot concerning for trauma were found in 5 children (4.3%),including lack of septum pellucidum, known migratoryanomalies, low lying cerebellar tonsils, small intraventricularhemorrhage of posterior cerebellar horns related to birthtrauma, and small ventricles. One child with head imaginghad extracranial findings of soft-tissue swelling that was notnoted on the skull radiograph. Clinical documentation wasinsufficient to determine whether the swelling had been seenon physical examination. The remaining 5 children (4.3%)had traumatic head injuries identified on the head CT. Theclinical characteristics of these 5 children that weredocumented in their medical records are detailed in Table I.Further historical and clinical details were obtained on the

traumatic cases to better describe the children at risk for headinjury. Three of the patients with high suspicion of abuse alsohadmedical histories concerning for NAT. In these 3 patients,the head CT findings increased the concerns for NAT andtherefore were forensically significant. Two patients had smallsubarachnoid hemorrhages that resolved the next day. Onepatient was hospitalized for 2 days to facilitate completionof NAT workup, not specifically because of the head injury.Therefore, none of the patients had clinically significant trau-matic brain injury according to the PECARN criteria.5,14

Medical records of patients who did not receive a head CTduring the evaluation with the skeletal survey were further re-viewed to identify children with potentially missed cases ofacute head injury during the evaluation of the isolated ex-tremity fracture. Of the 203 children who did not have ahead CT during the initial evaluation, 2 (1%) had a normalhead CT obtained 3 days after their initial presentation.Table II outlines multivariate analysis of the rate of head

CT and patient variables. For each age group, the odds ofhead imaging within that group compared with the rest ofthe age groups were determined. Infants in the 0-3 and 4-6month age groups were more likely to have a head CTincluded in their work-up compared with children in theolder age groups. In regards to location of fracture, odds ofobtaining a head CT were calculated for proximal versusdistal and upper versus lower extremity fractures. Infantsand children with proximal (humerus or femur) extremityfractures were 4 times as likely to be evaluated with a headCT compared with those with distal extremity fractures.There was no significant difference in the rate of headimaging for upper versus lower extremity fractures.

Discussion

Despite the recommendations regarding skeletal imaging ofchildren younger than 2 years of age with suspected NAT,no comparable guidelines currently exist for intracranialimaging of children younger than 2 years of age with an acuteisolated extremity fracture. Previous recommendations havefocused on clinical indications for imaging in children withminor head trauma or abusive head trauma,7,9,15 but thisstudy is the first to address the clinical and forensic

Wilson et al

Table

I.Childrenwithtraumaticfindings

onheadCT

Age,

mo

Sex

Reportedhistory

Pertinent

medical

history

Physicalexam

inationfindings

Extrem

ityfracture

HeadCTresults

Abuse

suspicion

Durationof

hospitalization

9M

Irritability,concernforlegpain

bypediatrician

Burns

toextrem

ities

at7weeks

ofage,abusereportmade

Painwith

hipmovem

ent,GCS

score=15

Leftdistalfemur

fracture

Nondepressedrightoccipitalskull

fracture

High

1day

5F

Unrestrainedincarseaton

kitchencounter

Interm

ittentpainwith

palpation

ofarm,norm

alneurologic

exam

Leftsupra-condylar

humerus

fracture

Tiny

SAHoftheleftlateralfrontallobe

Low

1day

5F

Legpain

Apnea

andseizures

at2months

ofage,posteriorribfractures

anddiffuseischem

icbrain

injury

Swellingofrightleg,fussy

Rightfemur

fracture

Acuteor

chronicSDH,hypoxic

ischem

icencephalopathy

High

1day

5M

Falldownstairswith

mom

’sboyfriend,notactingnorm

ally

Historyofblackeyeat2months

ofage

Possibleretinalhemorrhages

notedon

EDexam

ination

Bucklefracture

distalright

tibia

ChronicSDHbilaterally,rightparietal

convexity

encephalom

alaciacaused

byprevious

trauma

High

2days

4F

Fallfrom

bedtocarpeted

floor

unattended

Prem

aturity

Swellingtolefttemple,leftthigh

bruisedandsw

ollen

Rightproximalfemur

fracture

Tiny

leftfrontalSAH,historyof

gradeIVIVH

Low

1day

F,female;GCS,Glasgow

Com

aScale;IVH,intraventricular

hemorrhage;M,male;SAH,subarachnoidhemorrhage;SDH,subduralhemorrhage.

Table II. Multivariate analysis of the rate of head CT

VariableFrequency ofhead imaging OR 95% CI P value

Age, mo0-3 31/58 2.35 1.32-4.18 <.054-6 36/61 3.16 1.78-5.62 <.057-12 36/126 0.56 0.35-0.90 <.0513-24 14/75 0.32 0.17-0.60 <.05

Proximal vs distal extremityProximal 103/234 4.04 2.16-7.58 <.05Distal 14/86

Upper vs lower extremityUpper 43/138 0.66 0.41-1.05 .08Lower 74/182

June 2014 ORIGINAL ARTICLES

Utility of Head Computed Tomography in Children with a Single E

significance of concomitant head injury in children in thisspecific population that we hypothesized would be low risk.Although CT scans are readily available, less than 4%-8%

of head CTs performed in children with minor head traumademonstrate any evidence of traumatic brain injury, witheven fewer requiring neurosurgical evaluation.7,16 It isnotable that 1:1000-5000 pediatric patients could be at riskof developing lethal intracranial malignancies from theincreased exposure to ionizing radiation associated with asingle CT scan.17,18 Young children may require sedation toobtain quality imaging, with its own added side effects,including desaturations, transient respiratory depression,and aspiration.19 In addition, the discovery of incidentalfindings may lead to further imaging, which may be clinicallyunwarranted.20 These factors, in conjunction with the highcosts associated with head imaging, should encourage physi-cians to be judicious when ordering CT scans.Inconsistencies in study designs and inclusion criterion

make it difficult to develop imaging algorithms for this pop-ulation. In a retrospective study, Thomas et al21 demonstratedthat humerus fractures were more commonly a result of NATbut femur fractures often were accidental in a mobile child. Ameta-analysis by Maguire et al11 showed that long bone frac-tures in association with ICI was a weak predictor for inflictedbrain injury, but the authors did not exclude CMLs and didnot determine the association between the isolated longbone fractures and this outcome. Conversely, a meta-analysis done by Piteau et al22 demonstrated that long bonefractures were significantly associated with inflicted braininjury. Our study aimed to provide additional clarity to thecurrent literature by describing the clinical and forensic utilityof head CTs in children with an acute isolated extremity frac-ture and an otherwise-negative skeletal survey.We found that of the 320 children being evaluated by skel-

etal surveys for an isolated extremity fracture, 37% receivedneuroimaging, 95.7% of which had no signs of skull fractureor intracranial trauma. This information is important notonly for developing future guidelines for this low-risk groupbut also to help reduce unnecessary radiation in the form ofhead CTs. The majority of children in our study with trau-matic findings were <6 months of age, echoing results fromRubin,9 Gruskin,23 and Laskey.10 This greater-risk

xtremity Fracture 1277

THE JOURNAL OF PEDIATRICS � www.jpeds.com Vol. 164, No. 6

population illustrates an age group in which screening withhead CT may be warranted. We also noted a correlation be-tween clinicians ordering more head imaging if a proximalextremity bone was fractured. We speculate that the clini-cians in our study may have thought that proximal bone frac-tures were more concerning because the femur and humerusare larger, denser bones and hypothetically more difficult tofracture.

When evaluating children with concerns for NAT, the pur-pose of imaging is to identify injuries that have forensic sig-nificance as well as clinically significant injuries that requiremedical intervention. In many cases, the forensic value ofidentifying injuries is equally important because it can illus-trate the extent of injury and help demonstrate that a childhas been in an abusive environment. Therefore, we analyzedour data from both clinical and forensic perspectives. Tofurther standardize the classification of clinically importanttraumatic brain injuries, we used previously defined PE-CARN criteria that were generated from collaborationbetween multiple pediatric EDs.5,14 We elected to use the PE-CARN criteria because the evaluation of isolated extremityfractures occurs most often in the ED setting. It is notablethat none of the patients with isolated extremity fracturesand positive head CT findings in our study had clinically sig-nificant head injury as defined by these criteria.

However, the potential forensic significance of positive headCT findings is worth considering. Three of the patients in ourstudy hadfindings on headCT that supported the concerns forNAT. All 3 of these patients had medical histories concerningfor NAT. This high-risk population would warrant furtherwork-up including imagingwith headCT regardless of clinicalpresentation or concomitant fractures. Our data illustrate thatcareful consideration should be given to obtaining imaging inhigh-risk populations in which identification of forensicallysignificant injuries would be particularly valuable.

This study included a very specific population and thefindings cannot be generalized to children with nonskeletalinjuries concerning for abuse. In addition, the presence ofpsychosocial risk factors in the family should be stronglyconsidered when deciding on the extent of an evaluationfor NAT. Therefore, it is imperative for the clinician toconsider risk factors in addition to the isolated extremityfracture that could increase the forensic concern for abuse.Also, our inclusion criteria stated that the skeletal surveyshould have been obtained for concerns of an extremity frac-ture, and not because of bruising patterns, changes in mentalstatus, concerning history, or psychosocial risk factors. Thesefindings in addition to an occult extremity fracture wouldheighten the clinician’s concern for abuse, and would there-fore place the child in a greater-risk population.

The majority of children in the study did not receive headimaging; therefore, no assumptions can be made regardingthe forensic significance of the isolated extremity fracturesof the children in this group.We speculate that ED physiciansmay not have obtained head imaging in this group of patientssecondary to the normal clinical appearance of the patient,preference for prolonged observation in the ED after injury,

1278

or parental story consistent with injury. Medical record re-view for this group of patients did not identify any potentialmissed cases of head injury within 7 days of initial evaluation.Although it is possible that a child may have been seen atanother facility, we are the only tertiary care referral centerin a tri-state area. Therefore, it is likely that any case of clin-ically significant head injury would have been transferred toour institution and identified in the medical record review.In any retrospective study, analysis is limited by and

dependent on the level of documentation. Our data collec-tion did not include information regarding the presence orabsence of cutaneous injuries, neurologic examinations, orphysician/social services degree of concern for abuse beforereceiving results of radiologic studies. We understand thatchildren with abnormal neurologic findings or bruising areat higher risk for abuse and would likely have a head CT ob-tained regardless of the results of the skeletal survey, but wealso agree with previous studies indicating that asymptom-atic children with normal neurologic findings may stillhave abusive head trauma.8,10 Therefore, we chose to includeonly objective radiographic information that could be consis-tently obtained and would not be limited by variability indocumentation.The skeletal surveys and head CTs in our study population

were read by a variety of radiologists at our institution, ratherthan a single individual. Although variability does exist in theexpertise of those reading the images, this reflects real clinicalpractice and increases the generalizability of our results. n

Thanks to Dr Linda Levin (Center for Clinical and Translational Sci-ence and Training) and Ms Mona Ho (Cincinnati Children’s HospitalMedical Center) for aiding us in our statistical analysis.

Submitted for publication Oct 3, 2013; last revision received Nov 12, 2013;

accepted Dec 18, 2013.

Reprint requests: PariaMajdWilson,MD, Department of EmergencyMedicine,

Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, OSB-4,

Cincinnati, OH 45229. E-mail: paria.wilson@gmail.com

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