26: A Clinical Decision Rule to Identify Skull Fracture Among Young Children with Isolated Head Trauma
Bibliographic record
Abstract
There is no clear consensus regarding the use of skull radiological evaluation for young children who sustained a head trauma without traumatic brain injury. The primary objective of this study was to derive and validate a clinical decision rule to identify skull fracture among children younger than two years of age with head trauma and no need for head tomography. This was a prospective cohort study performed in three tertiary care pediatric emergency departments. Participants were all children younger than 24 months of age who sustained a head trauma and for whom head tomography was not highly recommended according to the PECARN head CT scan rule. The primary outcome was the presence of a skull fracture according to radiological report. A-priori, 28 independent variables were identified through a literature review and experts consensus. All participants were initially evaluated by a physician using a standardized datasheet before radiological evaluation. Radiological evaluation was left to the treating physician discretion. A clinical decision rule was derived using recursive partitioning. It was estimated that a sample of 45 cases of fracture would be necessary to derive the rule. Then, a second sample including at least 40 patients with a skull fracture were prospectively recruited for the validation. A total of 811 patients were recruited during the derivation period. Among them, 49 had a skull fracture. Recursive partitioning was used to derive a simple clinical decision rule to identify skull fracture. Parietal or occipital swelling/hematoma and age younger than two months of age were the items of the rule. It showed a sensitivity of 94% (95% CI 83% to 99%) and specificity of 86% (95% CI 845 to 89%) in the derivation phase. Subsequently, 856 participants were recruited during the validation phase including 44 with a skull fracture. The clinical decision rule had a sensitivity of 89% (95% CI 76% to 95%) and a specificity of 87% (95% CI 84% to 89%). Using the rule would have decreased the number of radiological evaluation from 366 to 148. Four of the five missed fractures were in children younger than four months of age. This clinical decision rule identifies young children at higher risk of skull fractures following an acute head trauma with no definitive indication for head tomography.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.016 | 0.072 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.002 | 0.002 |
| Bibliometrics | 0.004 | 0.002 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.001 |
| Open science | 0.003 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".