Clival fractures in children: a challenge in the trauma room setting!

Objective: A clival fracture is a rare but life-threatening traumatic brain injury in the adult and pediatric populations. To date, there are very few conclusive recommendations in the literature concerning the diagnosis and treatment of pediatric clival fractures.

Methods: In 2014 and 2015, two pediatric patients with severe blunt head trauma and clival fractures were evaluated and treated at a level I trauma center. Both cases are documented and supplemented by an extensive review of the literature focusing on the diagnostic workup, classification, and clinical course of clival fractures in children.

Results: The clinical course of two children (8 and 9 years old) with clival fractures in concert with other intra- and extracranial injuries was analyzed. A total of 17 papers encompassing 37 patients (age range, 1-18 years) were included for a systematic review. The literature review revealed a mortality rate of 23% in pediatric patients with a clival fracture. Over 50% of the patients presented with cranial nerve damage, and two-thirds suffered from intracranial vascular damage or intracerebral bleeding.

Conclusions: Clival fractures are a very rare but severe consequence of blunt head trauma in the pediatric population and may be challenging to diagnose, especially in cases with an unfused sphenooccipital synchondrosis. Vascular damage following clival fractures appears to be as common in pediatric patients as in adults. Therefore, contrast-enhanced CT of the cervical spine and head and/or magnetic resonance angiography is strongly recommended to rule out vascular injury of the extra- and intracranial brain-supplying vessels within the trauma room setting.