Pediatric abuse head injury workup: are both X-ray and CT required?

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Takeaway

  • Results of this study suggest that skull X-ray may be redundant during nonaccidental injury (NAI) workup that includes diagnostic-quality head CT.

Why this matters

  • A 2008 standard from the Royal Colleges of Radiologists and of Paediatrics and Child Health recommended skull X-rays plus head CT in NAI workups; authors note recommendation was based on older research.
  • Volumetric imaging via helical CT has largely superseded older step-and-shoot individual image technique.

Key results

  • CT detected 17 cases of intracranial pathology (18%), including 13 skull fractures, 2 not detected on skull X-rays.
  • No skull radiograph detected intracranial pathology.
  • Researchers calculated it is 95% certain that the rate of findings visible on X-ray, but not CT, is

Study design

  • Literature review, retrospective cohort study, 94 patients aged 24 days to 23 months presenting with possible NAI to a British emergency department.
  • All patients had both skull X-rays and noncontrast head CT.
  • Outcome: proportion of injuries on skull X-ray and not CT.
  • Funding: None.

Limitations

  • Small study, single tertiary center with pediatric radiologists.
  • More research needed to confidently eliminate skull CT.
  • Royal Colleges 2017 recommendations replaced 2008 edition; they still call for skeletal survey (which includes skull X-ray) plus head CT.