Evaluation of isolated skull fractures in children Sommer L. Glasgow a, * , Jack H. Scaife a , Christopher E. Clinker a , Anastasia M. Kahan a, Hsuan-Yu Wan a , Annika B. Kay b , Davian J. Martinez a , Vijay M. Ravindra c , Robert A. Swendiman a , Katie W. Russell a a University of Utah, Department of Surgery, Division of Pediatric Surgery, Salt Lake City, UT, USA b Intermountain Health, Intermountain Medical Center, USA c University of Utah, Department of Neurosurgery, Division of Pediatric Neurosurgery, Salt Lake City, UT, USA a r t i c l e i n f o Article history: Received 3 October 2025 Accepted 19 October 2025 Keywords: Pediatric trauma Isolated skull fracture Kids brain injury guidelines a b s t r a c t Background: The Brain Injury Guidelines (BIG) was recently adapted to pediatric patients by developing a pediatric-specific risk stratification algorithm, BIG for Kids (kBIG).(1) Children differ from adults in injury patterns and have a higher prevalence of isolated skull fractures without intracranial hemorrhage (ICH). Given the frequency of this injury pattern, a distinct kBIG 0 category was created. This study aimed to better characterize isolated skull fractures in children. We hypothesized that these fractures carry a low risk of ICH development or neurosurgical intervention. Methods: We conducted a retrospective cohort study of pediatric patients (<18 years) with isolated skull fractures treated at a Level 1 pediatric trauma center from January 2018 to April 2024. Data collected included demographics, injury characteristics, location of fracture, repeat head CT, and neurosurgical intervention. Fractures were classified as nondisplaced, minimally displaced (< one cra- nium width), or displaced (≥ one cranium width). Results: Among 431 children, 63 % had nondisplaced, 27 % minimally displaced, and 10 % displaced fractures. Fracture locations most commonly involved the parietal, frontal, and occipital bones. ICH progression occurred in six patients (1.4 %), all with low Glasgow Coma Scale rating (GCS) or suspected hemorrhage. Nineteen patients (4.4 %) required neurosurgical intervention: six had GCS <15, and 13 had displaced fractures requiring fracture elevation. Fracture location was nonsignificant. No patient with a normal neurologic exam and a nondisplaced or minimally displaced fracture required surgery. Conclusion: Children with isolated, nondisplaced or minimally displaced skull fractures and normal neurological exams had excellent outcomes. These patients do not require repeat imaging or neuro- surgical consultation. © 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). 1. Introduction Head trauma is a leading contributor to pediatric morbidity and mortality [3]. Skull fracture associated with TBI are frequently encountered in children due to increased relative head size and thinner, more pliable calvarium [4], and their fracture patterns differ from adults. Many of these skull fractures occur without associated ICH[2], and are thus classified as isolated skull fractures. Pediatric patients with isolated skull fractures account for a sub- stantial proportion of pediatric head trauma presentations [5], and prior studies have shown that children with isolated, non- displaced skull fractures rarely experience clinically significant traumatic brain injuries, neurological deterioration, or require neurosurgical intervention, documented as <1 % in multiple prior studies that looked at these outcomes [6—8]. Despite the fre- quency of these injuries and the minimal risk for clinical deterio- ration, current management of isolated skull fractures in children lacks standardization which has led to considerable variation in clinical practice, with many children requiring hospital admission, repeat neuroimaging, and neurosurgical consultation. The utility of these interventions has not been well established [5,9—11]. Our research group recently developed the Brain Injury Guidelines for Kids (kBIG) [1] to standardize management of pe- diatric TBI. As part of this effort, we introduced a management pathway for neurologically normal children with isolated skull fractures, referred to as kBIG 0. The therapeutic plan for kBIG 0 patients states that they can be safely discharged from the * Corresponding author. 100 N Mario Capecchi Drive, Suite 800, Salt Lake City, UT 84113, USA. E-mail address: sommer.glasgow@hsc.utah.edu (S.L. Glasgow). Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.sciencedi rect.com/journal/ journal-of-pediatric-s urgery https://doi.org/10.1016/j.jpedsurg.2025.162766 0022-3468/© 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Journal of Pediatric Surgery 61 (2026) 162766
Emergency Department (ED) with no hospitalization, no repeat head CT, and no neurosurgical consultation [1]. Despite this advancement, a critical knowledge gap remains: how specific characteristics of isolated skull fracture patterns in children in- fluences management decisions and outcomes is not yet defined. The objective of our study was to further characterize skull fracture patterns in pediatric patients presenting without ICH. Specifically, we aimed to evaluate whether location of fracture and/or degree of fracture displacement correlate with subsequent hemorrhage development or need for operative intervention. We hypothesized that patients with nondisplaced or minimally dis- placed fractures who are otherwise clinically stable could be safely discharge home from the ED. We additionally wanted to investi- gate fracture location as a correlate for neurosurgical intervention. 2. Methods 2.1. Study design and data source Following approval from the Institutional Review Board (#00176573), we conducted a retrospective study of pediatric trauma patients (<18 years) with isolated skull fractures treated at our Level 1 pediatric trauma center between January 2018 and April 2024. Initial data was extracted from the trauma registry, followed by an in-depth chart review. We included all patients with isolated skull fracture without intracranial hemorrhage identified on initial head CT (kBIG 0 and kBIG 3 due solely to fracture displacement >1 cranium width). kBIG 0 fractures were defined as isolated skull fractures without ICH on initial CT; patients who later developed hemorrhage on repeat CT were still categorized as kBIG 0 by initial definition. We excluded all patients that had evidence of ICH on initial head CT. Other exclusion criteria included patients with penetrating injuries and no radiographic evidence of TBI. Data extraction was performed through electronic medical re- cord review, and CT head images were reviewed for skull fracture data which included level of displacement, location of skull frac- ture, and presence of pneumocephalus. Dictated reports of initial CT head images were used in most cases; images were re-reviewed in cases of incongruent findings or documented progression. Neurosurgical operation details were extracted from operative notes. Fractures were categorized as frontal, parietal, temporal, occipital, skull base, sphenoid, and 2 or greater bones involved. Skull fractures were also categorized as non-displaced, minimally displaced (displacement ≤1 cranium width) or displaced (displacement >1 cranium width) [12]. Neurosurgical operations included craniotomy, fracture elevation, intracranial pressure monitoring, craniectomy, and cranioplasty. Progression on repeat head CT (RHCT) was defined as the development of any new ICH for the isolated skull fractures. kBIG classification was performed for each patient according to the published guideline [1]. 2.2. Statistical analysis Data analysis was performed using R software (version 4.5.1, R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistics were used to summarize patient demographics, baseline characteristics, and clinical outcomes. Continuous variables were presented as median with interquartile range and analyzed using Mann—Whitney U test or Kruskal—Wallis test. Categorical variables were expressed as frequency and percentage and analyzed using the chi-square test or Fisher's exact test. To test our primary hypothesis, univariate analyses were conducted to compare clinical outcomes (intracranial hemorrhage progression and neurosurgical require- ment) between levels of fracture displacement (non-/minimally displaced and displaced). Multivariable logistic regression was then used to identify independent predictors of these outcomes, adjust- ing for age, which was examined due to its potential influence on fracture biomechanics. Age, however, was not a statistically signif- icant predictor of either hemorrhage progression or neurosurgical intervention in our models. Additionally, as an exploratory analysis, the cohort was stratified by fracture displacement to examine the isolated effect of fracture location on the study outcomes. Statistical significance was defined a two-sided p-value <0.05. 3. Results A total of 431 patients met inclusion criteria: 389 with non-/ minimally displaced fractures and 42 with displaced fractures (Ta- ble 1). Median age was 5 years (IQR 1—10), with displaced fractures occurring more often in older children (p = 0.024). The majority of fractures involved the parietal, frontal, or occipital bones (Table 1). 3.1. Fracture displacement and associated outcomes Repeat head CT was obtained in 21 % of patients, more often in displaced fractures (45 %) than non-/minimally displaced (21 %) (p < 0.001). Pneumocephalus occurred in 23 % of patients with no significant difference across groups. ICU admission was more frequent in the displaced group (21 %) compared to the non- displaced and minimally displaced groups (11 %) (p = 0.057). Neurosurgical consultation was obtained in 64 % of patients, including 86 % with displaced fractures (p = 0.003). Operative neurosurgical intervention was required in 19 total patients (4.4 %), 14 with displaced fractures (33 %) and 5 with non/mini- mally displaced fractures (1 %) (p < 0.001). Among displaced fracture cases, 13 underwent fracture elevation and 1 underwent ICP monitoring alone. In contrast, non/minimally fractures had 2 craniotomies with ICP monitoring, 2 ICP monitoring placements alone, and 1 craniectomy. Each of these interventions in the non- displaced and minimally displaced groups were required in pa- tients with GCS<15. All patients who underwent neurosurgical intervention had either a displaced fracture or an abnormal neurologic examination (GCS <15). No patient with a normal neurologic exam and a nondisplaced or minimally displaced fracture, patients defined as kBIG 0, required surgery. 3.2. Fraction location and associated outcomes Analysis by fracture locations revealed that the majority of fractures occurred in the parietal, frontal, and occipital bones (Fig. 1), with 66 patients having fractures in two or more bones that were either contiguous or rarely, two separate locations. Fracture location was not independently associated with hemor- rhage progression or neurosurgical intervention in adjusted ana- lyses. Exploratory stratification showed that displaced fractures were most frequent in frontal (16 %) and parietal (11 %) locations. ICU admission rates were highest in multi-bone fractures (24 %) and frontal injuries (10 %) (Table 3). ICU admission rates were highest in frontal (10 %), parietal (5 %), occipital (9 %), and two- bone (24 %) fractures (p < 0.001). Operative intervention was most common in displaced frontal fractures (47 %) and parietal fractures (38 %) (Table 3). However, when limited to non-/minimally dis- placed fractures, operative rates were low and not significantly different by location (Table 2). 3.3. Progression cases and outcomes Progression (development of new ICH) on repeat head CT was rare, occurring in 6 (1.3 %) patients: 4 with nondisplaced, 2 with minimally displaced, and no displaced fractures (Table 4). Fracture S.L. Glasgow, J.H. Scaife, C.E. Clinker et al. / Journal of Pediatric Surgery 61 (2026) 1627662
locations varied but temporal bone involvement was noted in 3 cases. Of the nondisplaced and minimally displaced, 4 of these patients had a low presenting GCS (<15), and 1 other had initial CT findings concerning for ICH. Neurosurgical consultation was ob- tained in all but 1 case, where a discharged patient returned with new swelling and was found to have a small extra-axial bleed categorized as kBIG 1 and required no intervention. Excluding the displaced fractures, 4 patients, all with GCS<15, underwent neurosurgical procedures: 1 craniotomy, 2 ICP monitor, and 1 craniotomy and ICP monitor. ICU stays ranged from 0 to 15 days, correlating with neurologic severity. Five of the 6 total progression cases had suspected hemorrhage based on imaging or clinical signs. Only 1 patient (Case 1) had no hemorrhage concern and was diagnosed on ED return with a nondisplaced parietal fracture and GCS 15 (Table 4). 4. Discussion In this retrospective study, children with isolated, nondisplaced or minimally displaced skull fractures and a normal neurological examination had universally favorable outcomes, with none of these patients requiring neurosurgical intervention. Across the full Table 1 Demographics and clinical outcomes of pediatric patients with isolated skull fracture. All (N = 431) Non-/Minimally Displaced (n = 389) Displaced (n = 42) P-value Demographics Age, year a 5 (1, 10) 4 (1, 9) 7 (3, 12) 0.024 Sex b 0.747 Female 169 (39 %) 154 (40 %) 15 (36 %) Male 262 (61 %) 235 (60 %) 27 (64 %) Race c 0.273 American Indian/Alaska Native 4 (1 %) 4 (1 %) 0 (0 %) Asian 8 (2 %) 8 (2 %) 0 (0 %) Black 8 (2 %) 8 (2 %) 0 (0 %) Pacific Islander/Native Hawaiian 10 (2 %) 7 (2 %) 3 (7 %) White 345 (80 %) 308 (79 %) 37 (88 %) Ethnicity b 0.750 Hispanic 50 (12 %) 44 (11 %) 6 (14 %) Non-Hispanic 381 (88 %) 345 (89 %) 36 (86 %) Clinical Outcomes GCS b 0.951 14—15 386 (90 %) 349 (90 %) 37 (88 %) ≤13 45 (10 %) 40 (10 %) 5 (12 %) Fracture location c 0.044 Frontal 107 (25 %) 90 (23 %) 17 (40 %) Occipital 89 (21 %) 86 (22 %) 3 (7 %) Parietal 118 (27 %) 105 (27 %) 13 (31 %) Temporal 49 (11 %) 46 (12 %) 3 (7 %) 2+ bones 66 (15 %) 60 (15 %) 6 (14 %) Other (skull base, sphenoid) 2 (0 %) 2 (1 %) 0 (0 %) Pneumocephalus b 0.115 Yes 97 (23 %) 83 (21 %) 14 (33 %) No 334 (77 %) 306 (79 %) 28 (67 %) Repeat head CT b <0.001 Yes 91 (21 %) 72 (19 %) 19 (45 %) No 340 (79 %) 317 (81 %) 23 (55 %) Progression on repeat CT c 0.337 Yes 6 (1 %) 6 (2 %) 0 (0 %) No 85 (20 %) 66 (17 %) 19 (45 %) Neurosurgical consultation b 0.003 Yes 274 (64 %) 238 (61 %) 36 (86 %) No 157 (36 %) 151 (39 %) 6 (14 %) Neurosurgery b <0.001 Yes 19 (4 %) 5 (1 %) 14 (33 %) No 412 (96 %) 384 (99 %) 28 (67 %) Neurosurgical intervention c <0.001 Craniectomy 1 (0 %) 1 (0 %) 0 (0 %) Craniotomy 14 (3 %) 2 (1 %) 12 (29 %) Cranioplasty 2 (0 %) 0 (0 %) 2 (5 %) Fracture elevation 13 (3 %) 0 (0 %) 13 (31 %) ICP Monitor (EVD, bolt) 5 (1 %) 4 (1 %) 1 (2 %) ICU admission b 0.057 Yes 49 (11 %) 40 (10 %) 9 (21 %) No 382 (89 %) 349 (90 %) 33 (79 %) Length of ICU stay, day a 1 (1, 4) 2 (1, 4) 1 (1, 1) 0.181 Discharge location c 0.215 Deceased 2 (0 %) 1 (0 %) 1 (2 %) Home Health 4 (1 %) 4 (1 %) 0 (0 %) Home 375 (87 %) 337 (87 %) 38 (90 %) Rehab 6 (1 %) 5 (1 %) 1 (2 %) Other 2 (0 %) 2 (1 %) 0 (0 %) Data were compared between Non/Minimally Displaced and Displaced using a Mann-Whitney U test, b chi-square test, and c Fisher's exact test. GCS: Glasgow coma scale; CT: computed tomography; ICP: intracranial pressure monitor; EVD: external ventricular drainage; ICU: intensive care unit. S.L. Glasgow, J.H. Scaife, C.E. Clinker et al. / Journal of Pediatric Surgery 61 (2026) 162766 3
cohort, only six children (1.4 %) experienced progression on repeat head CT, and just four of the nondisplaced/minimally displaced progression cases (0.9 %) ultimately required surgical intervention. All four children requiring surgery had either a displaced fracture or an abnormal neurologic exam (GCS <15), reinforcing that neurologically normal children with simple fracture morphology without displacement are extremely low-risk. Our findings sup- port the conservative management of children who meet kBIG 0 criteria and emphasize the clinical safety of forgoing hospitali- zation, repeat CT, and neurosurgical consultation in this popula- tion. Our results build on prior studies showing that isolated skull fractures without ICH rarely result in deterioration or require surgical management [2,5,13]. They also validate the recommen- dations of the recently developed kBIG guidelines, which advocate for ED discharge of children with nondisplaced or minimally dis- placed skull fractures and normal neurologic exams [1]. For children with TBIs, the most critical clinical outcomes to evaluate are clinical deterioration and need for neurosurgical intervention. Notably in our study, cases with ICH progression were randomly distributed across fracture types and locations. Critically, all six children with progression had either an abnormal neurologic examination or initial radiologic findings suspicious for ICH and thus were not isolated fractures. This is consistent with prior studies that highlight the predictive value of GCS and bleeding in identi- fying higher-risk patients [2,5]. Our data identified a single case of ICH progression in a patient who initially presented with a normal neurological exam and a low-risk skull fracture. Notably, although a 3 mm extra-axial hemorrhage was detected on a repeat head CT Fig. 1. Location and displacement of skull fractures Published with permission from byte-sci creative LLC, Artist: B. Strauch S.L. Glasgow, J.H. Scaife, C.E. Clinker et al. / Journal of Pediatric Surgery 61 (2026) 1627664
Table 2 Fracture location and associated clinical outcomes in non-or minimally displaced isolated skull fracture. Frontal (n = 90) Occipital (n = 86) Parietal (n = 105) Temporal (n = 46) 2+ bones (n = 60) P-value GCS a 0.245 14—15 78 (87 %) 79 (92 %) 98 (93 %) 42 (91 %) 50 (83 %) ≤13 12 (13 %) 7 (8 %) 7 (7 %) 4 (9 %) 10 (17 %) Pneumocephalus a <0.001 Yes 26 (29 %) 13 (15 %) 4 (4 %) 17 (37 %) 23 (38 %) No 64 (71 %) 72 (84 %) 101 (96 %) 29 (63 %) 37 (62 %) Progression on repeat CT a Yes 1 (1 %) 1 (1 %) 1 (1 %) 1 (2 %) 2 (3 %) 0.795 No 23 (26 %) 7 (8 %) 13 (12 %) 9 (20 %) 13 (22 %) Neurosurgery a 0.508 Yes 2 (2 %) 1 (1 %) 0 (0 %) 1 (2 %) 1 (2 %) No 88 (98 %) 85 (99 %) 105 (100 %) 45 (98 %) 59 (98 %) ICU admission b 0.151 Yes 10 (11 %) 8 (9 %) 6 (6 %) 5 (11 %) 11 (18 %) No 80 (89 %) 78 (91 %) 99 (94 %) 41 (89 %) 49 (82 %) Length of ICU stay, day c 4 (2, 6) 2 (1, 2) 1 (1, 2) 5 (2, 6) 1 (1, 2) 0.054 Discharge location a 0.636 Deceased 0 (0 %) 0 (0 %) 1 (1 %) 0 (0 %) 0 (0 %) Home Health 1 (1 %) 1 (1 %) 1 (1 %) 0 (0 %) 1 (2 %) Home 79 (88 %) 76 (88 %) 85 (81 %) 39 (85 %) 58 (97 %) Rehab 2 (2 %) 1 (1 %) 0 (0 %) 2 (4 %) 0 (0 %) Other 0 (0 %) 1 (1 %) 1 (1 %) 0 (0 %) 0 (0 %) Data were analyzed using a Fisher's exact test, b chi-square test, and c Kruskal-Wallis test. GCS: Glasgow coma scale; CT: computed tomography; ICU: intensive care unit. Table 3 Fracture location and associated clinical outcomes in displaced isolated skull fracture. Frontal (n = 17) Occipital (n = 3) Parietal (n = 13) Temporal (n = 3) 2+ bones (n = 6) P-value GCS a 0.003 14—15 16 (94 %) 3 (100 %) 13 (100 %) 3 (100 %) 2 (33 %) ≤13 1 (6 %) 0 (0 %) 0 (0 %) 0 (0 %) 4 (67 %) Pneumocephalus a 0.999 Yes 6 (35 %) 1 (33 %) 4 (31 %) 1 (33 %) 2 (33 %) No 11 (65 %) 2 (67 %) 9 (69 %) 2 (67 %) 4 (67 %) Progression on repeat CT a 0.999 Yes 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) No 8 (47 %) 1 (33 %) 7 (54 %) 0 (0 %) 3 (50 %) Neurosurgery a 0.333 Yes 8 (47 %) 0 (0 %) 5 (38 %) 0 (0 %) 1 (17 %) No 9 (53 %) 3 (100 %) 8 (62 %) 3 (100 %) 5 (83 %) ICU admission a 0.014 Yes 4 (24 %) 0 (0 %) 0 (0 %) 1 (33 %) 4 (67 %) No 13 (76 %) 3 (100 %) 13 (100 %) 2 (67 %) 2 (33 %) Length of ICU stay, day b 1 (1, 1) — — 1 (1, 1) 1 (1, 4) 0.855 Discharge location a 0.085 Deceased 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) 1 (17 %) Home Health 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) Home 17 (100 %) 3 (100 %) 11 (85 %) 3 (100 %) 4 (67 %) Rehab 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) 1 (17 %) Other 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) 0 (0 %) Data were analyzed using a Fisher's exact test and b Kruskal-Wallis test. GCS: Glasgow coma scale; CT: computed tomography; ICU: intensive care unit. Table 4 Cases with progression on repeat head CT. Case Fracture Displacement FractureLocation Mechanism ED GCS # of RHCT NS Consultation NS Intervention Pneumo- cepahlus ICU Days Suspected Hemorrhage 1 Nondisplaced Parietal Fall 15 1 None None No 0 No — identified on ED bounce back 2 Nondisplaced 2 bones (occipital, temporal) Bike 15 2 Yes None Yes 1 Yes — concern for open fracture 3 Nondisplaced Temporal Fall 14 3 Yes Craniotomy Yes 5 Yes — possible extra-axial seen on CT (motion artifact obscured image) 4 Nondisplaced 2 bones (occipital, temporal) Fall 3 1 Yes ICP monitor No 6 Yes — low GCS 5 Minimally displaced Frontal MVC 7 1 Yes ICP monitor No 10 Yes — low GCS 6 Minimally displaced Occipital Struck 7 1 Yes ICP monitor, craniotomy No 15 Yes — low GCS ICP monitor: intracranial pressure monitor; GSC: Glasgow Coma Scale; CT: computed tomography; ED: emergency department; NS: Neurosurgical. S.L. Glasgow, J.H. Scaife, C.E. Clinker et al. / Journal of Pediatric Surgery 61 (2026) 162766 5
during a return ED visit, the patient was safely discharged home without requiring intervention, suggesting that early discharge with strict return precautions is still appropriate. Similarly, Rollins et al., in a retrospective review of children presenting with an ED GCS of 15 and isolated skull fractures reported only one case of ICH pro- gression on repeat imaging, in which the patient also required no intervention and was safely discharged [14]. Aside from the single case in our study, we observed no further instances of ICH pro- gression in patients lacking initial clinical or imaging concerns, reinforcing the safety of a risk-stratified discharge strategy and aligning with prior data assessing the low likelihood of delayed hemorrhage [15,16]. These findings support that children with low- risk skull fractures, absent concerning neurological symptoms or radiographic features, can be considered for ED discharge with thorough return precautions and family education. Additionally, the recently published kBIG TBI guidelines [1] do not consider fracture location in the risk stratification of the pa- tient. In this study, we specifically evaluated clinical outcomes by fracture location. We found that the location of fracture does not predict likelihood of neurosurgical intervention or progression. Historically, occipital fractures have been associated with higher concern for clinical deterioration, given the risk of swelling in such a small space [17]. In our study, we found an extremely low operative intervention rate (n = 1 patient) among this subset of fractures, limited to one patient who had an ICP monitor placed due to an ED GCS of 3, categorizing this patient as a kBIG 3. Additionally, prior studies have found that isolated basilar skull fractures without concerning features including evidence of CSF leak, facial nerve injury, or hearing loss can be safely discharged from the ED with follow up [18]. Our findings suggest that fracture location is of little importance when taken into context of the entire clinical picture of the child, and fractures in specific loca- tions are not predictive of worse outcomes so long as they fall within the displacement guidelines for low-risk fractures. Our study demonstrates that pediatric patients with isolated skull fractures without initial ICH have a very low risk of clinical deterioration, need for neurosurgical intervention, or radiographic progression on repeat imaging. In our cohort, 33 % of patients with displaced fractures underwent operative intervention, nearly all involving fracture elevation procedures. These findings align with multiple prior studies that have identified displaced skull fractures as the most likely subset to warrant surgical management, typi- cally for fracture elevation [4,5,16,19]. In our cohort, there were two nondisplaced and two minimally displaced fracture patients who required operative interventions. Importantly, all four of these patients presented with low GCS ≤14. Thus, our findings reinforce that neurologically normal patients with minimally or nondisplaced fractures, are highly unlikely to require surgical intervention. Additionally, surgical interventions were almost exclusively reserved for patients with displaced fractures, pri- marily for fracture elevation rather than evacuation of hemorrhage or decompression, a finding that had not been delineated by pre- vious studies(20) Fracture displacement is the most reliable radiographic predictor of surgical need, and these findings are in line with the automatic upgrade of a displaced skull fracture to the highest TBI management category (kBIG 3) [1]. Our findings sup- port a management strategy in which children with an initial ED GCS score of 15 and a nondisplaced or minimally displaced skull fracture can be safely observed without mandatory repeat head CT or neurosurgical consultation. These results support the recom- mendations of the recently published kBIG TBI guidelines for the management of pediatric isolated skull fractures. Our study has several limitations. First, this was a retrospective review conducted at a single Level 1 pediatric trauma center, which may limit the generalizability of the findings to other institutions or patient populations. This study is also underpowered for the ana- lyses regarding the effect of fracture location on the primary outcome. Additionally, some patients underwent repeat head CT or neurosurgical consultation based on provider preference rather than standardized criteria, which could introduce selection bias. Concurrently we are conducting both retrospective and prospec- tive, multicenter studies to validate these findings and refine risk stratification protocols for children with isolated skull fractures. 5. Conclusion Pediatric patients with a normal neurologic exam and non- displaced or minimally displaced fractures isolated skull fractures did not progress in our study and none required neurosurgical intervention. In contrast, those with an abnormal neurological exam or depressed fracture had a high risk of surgery. These findings support a risk-stratified approach, confirming that routine repeat imaging and neurosurgical consultation are unnecessary in low-risk cases regardless of fracture location. Conflicts of interest The authors declare no competing financial interests or per- sonal relationships that could have influenced the work reported in this manuscript. References [1] Kay AB, Glasgow SG, Kahan AM, Russell KW, Mo JT, Castillo J, et al. Small change, BIG impact: proposal of the brain injury guidelines for kids (kBIG). J Pediatr Surg 2025;60(6):1134—9. [2] Waseem M, Esposito KD, Cedano K, Shariff MA, Priovolos S. The observation of pediatric skull fractures without an associated brain injury in a non- trauma center. Cureus 2023;15(12):e50571. [3] Blackwood BP, Bean JF, Sadecki-Lund C, Helenowski IB, Kabre R, Hunter CJ. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. J Pediatr Surg 2016;51(4):654—8. [4] McGrath A., Taylor R.S. Pediatric skull fractures. StatPearls 2025. [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. PMID: 29489156. [5] Donaldson K, Li X, Sartorelli KH, Weimersheimer P, Durham SR. Management of isolated skull fractures in pediatric patients: a systematic review. Pediatr Emerg Care 2019;35(4):301—8. [6] Ben Zvi I, Imtiaz G, Piper RJ, Tisdall MM. Should pediatric patients with isolated skull fractures be admitted, transferred, or discharged from the emergency department, and what are the economic consequences? Original series, systematic review of the literature, and a proposed admission pro- tocol. J Neurosurg Pediatr 2025;35(4):400—6. [7] Yu N, Castillo J, Kohler JE, Marcin JP, Nishijima DK, Mo J, et al. Validating the brain injury guidelines in a pediatric population with mild traumatic brain injury and intracranial injury at a level I trauma center. J Neurotrauma 2025;42(1—2):71—81. [8] Najmi VS, Yellamraju SK, Toman E, Elmaghraby M, Lo W, Gallo P, et al. Un- complicated linear skull fractures in the paediatric population: a retrospective observational study in a UK Major Trauma Centre. Br J Neurosurg 2024:1—4. [9] Reuveni-Salzman A, Rosenthal G, Poznanski O, Shoshan Y, Benifla M. Evalu- ation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF). Childs Nerv Syst 2016;32(9):1669—74. [10] Addioui A, Saint-Vil D, Crevier L, Beaudin M. Management of skull fractures in children less than 1 year of age. J Pediatr Surg 2016;51(7):1146—50. [11] Beaudin M, Saint-Vil D, Ouimet A, Mercier C, Crevier L. Clinical algorithm and resource use in the management of children with minor head trauma. J Pediatr Surg 2007;42(5):849—52. [12] Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, et al. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg 2014;76(4):965—9. [13] Ben Zvi I, Imtiaz G, Piper RJ, Tisdall MM. Should pediatric patients with isolated skull fractures be admitted, transferred, or discharged from the emergency department, and what are the economic consequences? J Neurosurg Pediatr 2025;35(4):400—6. [14] Rollins MD, Barnhart DC, Greenberg RA, Scaife ER, Holsti M, Meyers RL, et al. Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg 2011;46(7):1342—6. [15] Palavani LB, Bertani R, de Barros Oliveira L, Batista S, Verly G, Andreao FF, et al. A systematic review and meta-analysis on the management and outcome of isolated skull fractures in pediatric patients. Children 2023;10 (12):1913. S.L. Glasgow, J.H. Scaife, C.E. Clinker et al. / Journal of Pediatric Surgery 61 (2026) 1627666
[16] Bressan S, Marchetto L, Lyons TW, Monuteaux MC, Freedman SB, Dalt LD, et al. A systematic review and meta-analysis of the management and out- comes of isolated skull fractures in children. Ann Emerg Med 2018;71(6): 714—724.e2. [17] Morcos MM, Liu DS, Farid AR, See P, Hogue GD. Occipital condyle fracture in the pediatric population: a management algorithm and systematic review. J Child Orthop 2024;18(2):216—28. [18] Ryan S, Hewes H, Fenton SF, Russell K, Hansen K, Brockmeyer DL, et al. Ten- Year analysis of complications related to simple basilar skull fractures in children presenting to a trauma Center. Pediatr Emerg Care 2024;40(2): 137—40. [19] Bonfield CM, Naran S, Adetayo OA, Pollack IF, Losee JE. Pediatric skull frac- tures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr 2014;14(2):205—11. S.L. Glasgow, J.H. Scaife, C.E. Clinker et al. / Journal of Pediatric Surgery 61 (2026) 162766 7