Background: Infants with skull fractures are often admitted to the hospital for observation and testing due to concern about neurologic deterioration, need for neurosurgery, and child abuse.

Objective: To investigate factors associated with skull fractures in infants and to identify those factors associated with a low risk for neurologic deterioration, neurosurgery, or reporting to the community Child Protection Agency.

Design/Methods: Retrospective chart review of infants ≤ 24 months with a skull fracture presenting over a two year period. 131 charts of 133 cases were reviewed.

Results: 117 patients (89.3%) were admitted to the hospital. 5(4.3%) had neurologic deterioration and 12 (10.3%) required neurosurgery. Risk factors predictive of deterioration or neurosurgery included a depressed fracture and/or intracranial complication. 64 patients (54.7%) had neither risk factor and none (0%, 95% C.I. = 0 to 4.7%) experienced deterioration or required neurosurgery.

113 patients (96.6%) were evaluated by a social worker and 82 (70.1%) had a hospital Protective Services Team consultation. 30 (25.6%) were reported to the Child Protection Agency for either a high suspicion of abuse (17, 14.5%), neglect or delay in seeking care (8, 6.8%), or no story to explain the injury(5, 4.3%). Risk factors predictive of a report being filed included a moderate to high degree of social concern, unreasonable and/or inconsistent history, and other injury noted on examination. 75 patients (64.1%) had no social risk factor and none (0%, 95% C.I. = 0 to 4%) had other injury discovered on further evaluation. One low-risk patient (1.3%, 95% C.I. = 0 to 3.9%) was reported to the Child Protection Agency for delay in seeking care, but the injury was felt to be unintentional. 49 patients (41.9%) had neither a neurologic or social risk factor identified and none had neurologic deterioration, neurosurgery, other injury discovered, or a report to the Child Protection Agency.

Conclusions: Infants ≤ 24 months with a non-depressed skull fracture, no intracranial complication, low social concern, a reasonable and consistent injury history, and no other injury found on examination are unlikely to deteriorate, need neurosurgery, have other injury discovered, or to be reported to the Child Protection Agency. These infants may be managed as outpatients.