Objectives: To determine the incidence of skull fracture (SF) and intracranial injury (ICA) among children younger than 2 years evaluated in a pediatric emergency department for head trauma; whether historical features and/or physical findings are predictive of injury type; and whether clinical criteria could allow a selective approach to radiographic imaging. Design: Retrospective medical record review. Setting: Tertiary pediatric emergency department. Patients: Case series of 278 children aged younger than 24 months evaluated for head injury. Main Outcome Measures: Presence of SF and/or ICA. Results: Diagnoses at discharge included 227 minor head injuries, 39 isolated SF, 9 ICA with SF, and 3 isolated ICA. Children younger than 12 months had the highest incidence of SF/ICA (29%) vs 4% for children aged 13 to 24 months (P [is less than] .001). Seven percent of complications from SF/ICA resulted from falls greater than 3 ft (0.9 m). Incidence of behavioral change, loss of consciousness, emesis, and seizures did not differ significantly between those with minor head injuries and those with SF/ICA. Scalp abnormalities were more common in children with SF/ICA (P [is less than] .001). Sixty-two percent of children with isolated SF and 58% of children with ICA had no history of loss of consciousness, emesis, seizure, or behavioral change. Ninety-two percent of children with isolated SF and 75% of children with ICA had normal levels of consciousness and nonfocal neurologic examinations at diagnosis. Among children who fell 3 ft or more ([is greater than or equal to] 0.9 m) and had no loss of consciousness, emesis, seizure, behavioral change, or scalp abnormality, none of 31 (95% confidence interval [CI], 0-0.10) children younger than 24 months and none of 20 (95% CI, 0-0.15) children younger than 12 months had SF/ICA. Conclusions: Both SF and ICA are common in children younger than 2 years evaluated for head trauma. Children younger than 12 months are at highest risk. Injuries resulted from relatively minor falls and occurred in alert, neurologically normal children. Clinical signs and symptoms were insensitive predictors of SF/ICA; however, a grouping of features (fall [is less than or equal to] 3 ft [0.9 m], no history of neurologic symptoms, and normal scalp physical examination results) identified a subset of children at low risk for complications. Arch Pediatr Adolesc Med. 1999;153:15-20, Children who fall three feet or less and have no signs of neurologic damage or damage to the skull probably have a low risk of complications from the fall. This was the conclusion of an analysis of 278 children younger than two years old who were examined in a hospital emergency department. A total of 227 had minor injuries, 39 had skull fracture, three had an intracranial injury and nine had both. None of the children who had no loss of consciousness, vomiting, seizure, behavioral changes or scalp injuries developed a skull fracture or intracranial injury.