The Use of Bedside Ultrasound in the Detection of Skull Fractures in Pediatric Patients

Background: Head injuries are common in children and account for over 600 000 emergency room visits annually. Many children receive CT scans as part of their work-up to evaluate for intracranial injury. CT scans add risk of sedation and ionizing radiation, and recent effort has been made to reduce the amount of CT scans ordered in the evaluation of a head-injured child. Skull fractures are an independent risk factor for intracranial injury, and ultrasound may be of use to the clinician trying to detect these fractures. In the pediatric patient with a minor head injury, is ultrasound effective for the detection of skull fractures when compared to the reference standard CT? Methods: An exhaustive search of available medical literature was conducted on Medline-Ovid, Web of Science, and CINAHL-Ebscohost using the keywords “ultrasonography OR sonography” AND “skull fractures.” Reference lists from articles were examined, and any relevant sources were examined independently. The studies were evaluated and assessed using the GRADE method. Results: Three prospective studies were evaluated. Ultrasound was examined as a diagnostic modality for skull fracture detection and was compared against the reference standard of CT. Ultrasound was found to have high specificity (94%, 95%, and 97%) and moderate sensitivity (82%, 100%, and 88%) respectively, in detecting skull fractures in pediatric patients. Conclusion: Ultrasound detects skull fractures in children with high specificity, but this may not be relevant in clinical use. Clinical decision rules and algorithms, such as the PECARN score, are already well studied and used to guide clinicians in their evaluation of head-injured children. Future studies that evaluate ultrasound in conjunction with a clinical decision rule are needed to determine if the incorporation of ultrasound as a diagnostic modality will help decrease the use of CT scans in the pediatric population