Performance of computed tomography of the head to evaluate for skull fractures in infants with suspected non-accidental trauma

Pediatr Radiol. 2017 Jan;47(1):74-81. doi: 10.1007/s00247-016-3707-7. Epub 2016 Oct 15.


Background: Young children with suspected abusive head trauma often receive skull radiographs to evaluate for fractures as well as computed tomography (CT) of the head to assess for intracranial injury. Using a CT as the primary modality to evaluate both fracture and intracranial injury could reduce exposure to radiation without sacrificing performance.

Objective: To evaluate the sensitivity of CT head with (3-D) reconstruction compared to skull radiographs to identify skull fractures in children with suspected abusive head trauma.

Materials and methods: This was a retrospective (2013-2014) cross-sectional study of infants evaluated for abusive head trauma via both skull radiographs and CT with 3-D reconstruction. The reference standard was skull radiography. All studies were read by pediatric radiologists and neuroradiologists, with ten percent read by a second radiologist to evaluate for interobserver reliability.

Results: One hundred seventy-seven children (47% female; mean/median age: 5 months) were included. Sixty-two (35%) had skull fractures by radiography. CT with 3-D reconstruction was 97% sensitive (95% confidence interval [CI]: 89-100%) and 94% specific (CI: 87-97%) for skull fracture. There was no significant difference between plain radiographs and 3-D CT scan results (P-value = 0.18). Kappa was 1 (P-value <0.001) between radiologist readings of CTs and 0.77 (P = 0.001) for skull radiographs.

Conclusion: CT with 3-D reconstruction is equivalent to skull radiographs in identifying skull fractures. When a head CT is indicated, skull radiographs add little diagnostic value.

Keywords: Computed tomography; Fracture; Infant; Non-accidental trauma; Radiography; Sensitivity.

MeSH terms

  • Child Abuse*
  • Cross-Sectional Studies
  • Female
  • Humans
  • Imaging, Three-Dimensional
  • Infant
  • Male
  • Radiographic Image Interpretation, Computer-Assisted
  • Reproducibility of Results
  • Retrospective Studies
  • Sensitivity and Specificity
  • Skull Fractures / diagnostic imaging*
  • Tomography, X-Ray Computed / methods*