Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

BACKGROUND: After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home. OBSERVATIONS: Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection. LESSONS: In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.