POCUS on the brain

Mar 24

By Maria Tama, MD, RDMS

POCUS on the brain: cracking the case of pediatric skull fractures

Consider point-of-care ultrasound (POCUS) when you evaluate scalp hematomas in children with head injury. For children under 2 years, review the Infant Scalp Score (shown below) to help decide whether further imaging is warranted.

When to use skull ultrasound

Focal swelling or tenderness: scalp hematomas or focal swelling, and palpable step-offs or tenderness.
A mechanism concerning for skull injury.
When it is unclear whether CT is warranted, for example in intermediate-risk patients.

Technique ("so easy, even for the novice")

Use the linear probe.
Apply light pressure and plenty of gel so you do not distort the anatomy.
Identify the skull: a bright white (hyperechoic) line with posterior shadowing.
Scan the contralateral side to compare for asymmetry.

**Figure 2.** Technique: linear probe, light pressure, and plenty of gel. The skull is the bright line with shadowing.

Fracture or suture?

Sutures have an interlocking, symmetric appearance.
Fractures show a blunt disruption of the cortex.
An overlying hematoma is a clue that favors fracture.

**Figure 3.** Fracture versus suture line.

**Figure 4.** Skull fracture with overlying hematoma.

How POCUS helps

POCUS gives a rapid, radiation-free look at the skull under a hematoma. Combined with the clinical assessment, a validated decision rule, and the Infant Scalp Score for children under 2, it can help you decide which children need CT.

**Figure 5.** Infant Scalp Score, for children under 2 years.

**Figure 6.** How POCUS fits into the evaluation of pediatric head trauma.

Clinical pearls

Always compare with the other side. Sutures are paired and symmetric; fractures are not.
Do not compress the hematoma. Light pressure and lots of gel give the best image.
A fracture on POCUS changes your risk assessment. Combine it with the clinical picture to decide on further imaging.