fall, motor vehicle collision or assault However, in many instances, there is no accompanying history of a traumatic event Many infants will present with an isolated soft tissue swelling or scalp hematoma Other presentations may be nonspecific and include poor feeding, vomiting, irritability, a bulging anterior fontanelle, altered mental status defined as a Pediatric Glasgow Coma Score of less than or equal to 14 ( Table 113.1 ), lethargy, seizure, presence of scalp hematoma, palpable skull defect or crepitus Typical complaints in children include headache, localized pain or soft tissue swelling, vomiting, confusion, altered mental status defined as a GCS of less than or equal to 14 ( Table 113.1 ), seizure, lethargy, focal neurologic abnormality, obtundation, or signs of a basilar skull fracture ( Fig 113.5 ) The area of the skull most commonly involved is the parietal bone, followed by the occipital and temporal bones The physical examination may be normal as soft tissue swelling may not be present at the time of evaluation, or may include a scalp hematoma or soft tissue swelling, palpable skull defect or crepitus Signs of a basilar skull fracture ( Fig 113.5 ) include Battle sign, periorbital ecchymosis, hemotympanum, and CSF otorrhea or rhinorrhea A full neurologic examination is mandated to isolate any focal neurologic deficits These focal deficits are related to the underlying intracranial injury and allow for clinical detection of regional lesions The neurologic deficits frequently identified with basilar skull fractures include anosmia, nystagmus, hearing loss (either conductive or sensorineural), abducens nerve palsy, or facial paralysis Diagnostic Imaging As previously discussed, skull radiography has a limited role as it cannot provide details regarding intracranial injury CT is the preferred imaging modality for the initial evaluation as it allows for the detection of fractures utilizing bone windows, especially with threedimensional reconstruction capability Ultrasonography has been shown to be sensitive for the detection of skull fractures It has limited capability to detect underlying intracranial injury leading to a limited role in the initial evaluation of children with skull fractures It may be utilized emergently if there is no availability of CT to assist in facilitating transfer to a pediatric trauma facility Another future application may be outpatient follow-up settings monitoring skull fractures,