Presentation, Evaluation, and Outcomes of Infants Under 3 Months With Skull Fractures.

Background: Head injuries in infants are common but challenging to assess due to minor mechanisms potentially causing significant injury, nonspecific symptoms, and the risk of nonaccidental trauma (NAT).

Study objectives: This study evaluates clinical presentations, assessments, and outcomes in infants with skull fractures, with and without intracranial hemorrhage (ICH).

Methods: A retrospective chart review was conducted at a tertiary care children's hospital, identifying 291 infants (mean age: 6 weeks) with skull fractures via computed tomography imaging and ICD9/ICD10 codes.

Results: Most infants (80%, n = 232) had reported falls, and 83% (n = 240) presented with scalp hematomas. Glasgow Coma Scores were 14 to 15 in 81% (n = 234), while 1.5% (n = 5) scored below 8. ICH was present in 55% (n = 161), with subdural hemorrhage being the most common (53%, n = 86). Vomiting occurred in 8% (n = 23), with loss of consciousness rare (2%, n = 7). Provider-documented normal behavior (84%, n = 244) and parent-reported normal behavior (53%, n = 155) showed relative risks of 1.32 and 1.21 for ICH, respectively. Fracture type (75% nondisplaced/nondepressed, 21% displaced/depressed) did not predict ICH (p = 0.20). Critical care admission was required for 61% (n = 178), and 4% (n = 12) underwent surgery. Child welfare assessments were conducted in 64% (n = 186), more frequently in ICH cases (65%, n = 120 vs. 35%, n = 66; p < 0.001). Skeletal surveys (21%, n = 62) were abnormal in 24% (n = 15).

Conclusion: Infants under 3 months with skull fractures often present with minor injury mechanisms and subtle symptoms, yet over half have ICH, and nearly a quarter require evaluations for NAT. Clinicians should exercise caution when assessing head injuries in this age group.