Abnormalities were detected only in 24 (2.3%) of 1053 skull X-ray examinations performed in cases of suspected head trauma, at a cost of $1461 per positive finding. Only in six cases (0.6%) was treatment influenced by the radiological findings. Skull X-ray examination is indicated if a depressed fracture, compound fracture, or radio-opaque foreign body is suspected, and these patients are reliably selected by certain clinical criteria. The skull X-ray film is not a reliable guide to the presence or extent of intracranial injury, nor is it a substitute for careful clinical evaluation, observation and re-evaluation. The medicolegal implications of this restrictive policy are discussed.