Plain skull X-ray

Head injury

Headache and head trauma are common presenting problems in both primary care and the Accident and Emergency department. Plain skull X-ray (SXR) films (plain skull films) have largely been superseded by CT scanning and/or MRI scans in the context of both headaches and head injuries¹. This is also true in paediatric patients. Validated clinical tools do exist for evaluating the need for further imaging when the head trauma is fairly minor².

There is useful literature on the pre-hospital management of head injury and concussion³⁴.

Safeguarding in children and young people

SXRs are still useful where safeguarding investigations are being undertaken, to detect healing/healed injuries⁵. International guidelines for skeletal survey have been published by the American College of Radiology and the Society for Pediatric Radiology and the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. According to both guidelines, a complete radiographic series comprises at least 20 images and includes frontal and lateral skull views as a minimum⁶.

Indications for plain skull X-ray

Skull films are not indicated routinely for the following indications:

• Headache.

• Possible pituitary problems - (CT/MRI preferred).

• Possible space-occupying lesion.

• Epilepsy.

• Dementia or memory loss.

• Middle or inner ear problems.

• Nasal trauma - coned views may be requested by the appropriate specialist.

• Sinus disease - mucosal thickening is a common incidental finding and not diagnostic.

• Temporomandibular joint dysfunction - will not show disc abnormality, which is the most common cause of dysfunction.

Interpretation of skull films

Skull films should be interpreted wherever possible by a doctor with specialist radiological training and/or considerable experience in interpreting such films. In untrained hands approximately 10% of bony abnormalities are not recognised. The absence of a fracture on a skull film does not rule out the possibility of an operable intracranial haematoma in head-injured patients, which is why CT scanning is the investigation recommended in significant head injuries¹. All such findings must be taken in the context of the clinical condition of the patient.