[Undiagnosed skull fractures in a casualty ward. The importance of simple fractures of the skull for late sequelae].
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Child↗
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[Spontaneous resolution of a congenital depressed skull fracture].
Congenital depressed skull fracture is rare and in most cases its etiology remains unclear. We present a female newborn infant with a congenital depressed skull fracture and no evidence of antepartum or intrapartum traumatism. The baby had normal neurological status and the depressed fracture healed spontaneously in a few weeks. Based on our experience of this case and a literature review, we conclude that congenital depressed skull fractures should be managed conservatively if the skull depression is less than 2cm, there is no previous trauma, no local edema or hematoma, and if the neonate shows normal neurological status.
Female↗
Growing skull fractures.
INTRODUCTION: Growing skull fractures are a rare complication of head injuries (Ersahin et al. in Neurosurg Rev 23:139-144, 2000; Hayashi et al. in Childs Nerv Syst 13:349-351, 1997; Ramamurthi and Kalyanaraman in Neurosurgery 32:427-430, 1970; Zegers et al. in Eur J Pediatr 162:556-557, 2003). Although early diagnosis and prompt treatment are important to prevent the underlying progressive brain damage, the clinical presentation and the morphological investigations are rarely specific or sensitive shortly after the trauma. DISCUSSION: The authors present three cases of growing skull fractures: the use of ultrasonography (US) via the fracture line contributed to early diagnosis and prompt treatment in two cases. US was not performed in the third case, and this delayed management. Treatment consisted of a watertight duraplasty with a free flap of pericranium without cranioplasty. US via the fracture line appears to be a sensitive and reliable method of detecting the dural tears in the early stages of growing skull fractures. CONCLUSION: Duraplasty alone with a flap of pericranium remains the simplest and least expensive method of treatment. Cranioplasty is not necessary in young children.
Child, Preschool↗
Depressed skull fractures in children secondary to skull clamp fixation devices.
The use of external skull fixation devices (skull clamps) is a common practice in neurosurgery. The insertion of pins into the skull is usually routine and uneventful in adult patients. However, the safety of skull clamp fixation devices in children is not reported. We have examined our complications over the past 6 years, and have encountered 5 children with depressed skull fractures secondary to application of a skull clamp fixation device. There were 3 boys and 2 girls with ages ranging from 3 to 8 years (mean 5.8 years). Two patients had brainstem gliomas, 2 patients had hypothalamic gliomas and 1 patient had a medulloblastoma. Four of the children required separate cranial procedures for exploration and elevation of the depressed fractures. There were no sequelae associated with the depressed fractures. We conclude that skull clamp fixation devices are safe, but should be used with caution in the pediatric patient. In addition, we present several modifications of existing skull clamps which may decrease the risk of depressed skull fractures.
Brain↗
[Problems in skull fractures in children--with special reference to the experiences in cranioplasty and progressive skull fractures characteristic in children].
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Adolescent↗
[Pediatric skull fractures and child abuse. A critical comment on the contribution "Experimental studies of skull fractures in the infant" by W. Weber].
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Accidental Falls↗
Enlarging skull fractures in children.
Large skull fractures are conventionally followed radiographically until healing occurs. Fractures which enlarge or remain unhealed are commonly termed "leptomeningeal cysts" or "growing skull fractures". This study of ten children with this injury and a review of the literature shows that a true leptomeningeal cyst is seldom present and that skull fractures do not "grow". Moreover, careful history-taking and physical examination will correctly identify all enlarging or unhealed skull fractures of childhood without the need for plain radiographs or computed tomography of the skull.
Arachnoid Cysts↗
Skull fractures in children: their assessment in relation to developmental skull changes and acute intracranial hematomas.
Retrospective analysis of 12,072 pediatric head injury cases revealed 1,297 skull fractures. Patients with skull fractures were divided into four age groups according to the fusion of skull sutures and other developmental radiological skull changes. Results revealed that the patients with open skull sutures (aged less than 2 years) and with linear skull fractures alone had a negligible chance of developing intracranial hematomas. With the fusion of metopic and mendosal sutures associated with other skull changes (greater than 2 years), the children became progressively more susceptible to developing intracranial hematomas if they had a skull fracture. The risk of developing intracranial hematomas was the highest among those patients (much greater than 11-15 years) whose paranasal sinuses had reached adult size and spheno-occipital synchondrosis had begun to fuse.
Adolescent↗
A new biomechanically-based criterion for lateral skull fracture.
This work develops a skull fracture criterion for lateral impact-induced head injury using postmortem human subject tests, anatomical test device measurements, statistical analyses, and finite element modeling. It is shown that skull fracture correlates with the tensile strain in the compact tables of the cranial bone as calculated by the finite element model and that the Skull Fracture Correlate (SFC), the average acceleration over the HIC time interval, is the best predictor of skull fracture. For 15% or less probability of skull fracture the lateral skull fracture criterion is SFC < 120 g, which is the same as the frontal criterion derived earlier. The biomechanical basis of SFC is established by its correlation with strain.
Biomechanical Phenomena↗
Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures.
BACKGROUND: Basilar skull fractures (BSF) predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role for preventing bacterial meningitis is not established. OBJECTIVES: To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with BSF. SEARCH STRATEGY: We searched the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to September 2005), EMBASE (1974 to June 2005), and LILACS (1982 to September 2005). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis to compare results. DATA COLLECTION AND ANALYSIS: At least two authors independently appraised the quality and extracted the data of each trial. MAIN RESULTS: Five RCTs and 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with BSF were identified. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. Overall, we evaluated 208 participants from the four RCTs that were considered suitable for inclusion in the meta-analysis. There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), producing results consistent with the randomised data. AUTHORS' CONCLUSIONS: Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.
Antibiotic Prophylaxis↗
Statistically and biomechanically based criterion for impact-induced skull fracture.
This work developed a skull fracture criterion for impact-induced head injury, using post mortem human subject tests, anatomical test device measurements, statistical analyses, and finite element modeling. It is shown that skull fracture correlates with the tensile strain in the outer table of the cranial bone, and an index termed the Skull Fracture Correlate (SFC) predicts injury. SFC offers several advantages as a protection criterion. It accounts for compliance of the impact site; it is extensible to varying head mass; and it is easily implemented using current software. For a 15% or less probability of skull fracture the criterion is SFC < 120 g, with a 95% confidence band of 88 < SFC < 135 g.
Acceleration↗
The disappearing ellipse: a new sign of a linear skull fracture.
A linear nondepressed skull fracture may be seen as two connecting lines because slight angulation of the beam of radiation results in separate visualization of the fracture as it crosses the outer table and then the inner table. These two lucent lines form an elliptical shape. A second projection can result in superimposition of the inner and outer table fractures, and the elliptical configuration is no longer seen. This disappearing ellipse is offered as an additional sign of a linear skull fracture which can help differentiate such fractures from vascular grooves.
Diagnosis, Differential↗
Compound depressed skull fracture.
Although compound depressed skull fractures are common and their management and diagnosis have been described at length, their occurrence following dog bites is unusual. The case of an 18-month-old infant with this injury as a complication of multiple dog bites in the facial and head regions is described with the treatment employed. The necessity of searching for skull fractures in children following dog bites in this region is emphasized.
Animals↗
Growing skull fractures: strategies for repair and reconstruction.
Most skull fractures in growing children heal rapidly and without significant contour irregularity. Skull fractures in infants associated with dural injuries, however, may progressively enlarge as a result of bone erosion by leptomeningeal herniation at the dural tear sites and are known as "growing skull fractures." Over a 6-year period, seven growing skull fractures occurred in a population of 592 consecutive pediatric head injuries at Cardinal Glennon Children's Hospital (prevalence, 1.2%). Prompt recognition of growing skull fractures, repair by regional craniectomy and pericranial dural inlay graft, and immediate contour reconstruction with rigidly fixed cranial bone graft ensure reliable aesthetic and functional restoration of the growing neurocranium.
Biocompatible Materials↗
Shunt surgery in growing skull fractures: report of two cases.
Growing skull fractures indicate underlying brain damage which is an important aetiological factor in their development. Two cases of growing skull fractures managed successfully with shunt surgery are presented. In one, the growing skull fracture was associated with an underlying tense occipital porencephalic cyst and in the other with cystic encephalomalacia and hydrocephalus. Following shunt surgery, signs of raised intracranial pressure were relieved, improvement in neurological status was noted, regrowth of the bone edges was seen and major surgery including brain debridement was avoided. The role of shunt surgery in growing skull fractures in infants is discussed and relevant details highlighted.
Brain Diseases↗
Infection rate with replacement of bone fragment in compound depressed skull fractures.
BACKGROUND: Traditional management of compound depressed skull fractures entails elevation and removal of all bone fragments with delayed cranioplasty. Bone fragment removal is intended to reduce the potential for infection. However, bone fragment removal often necessitates a second operation to repair the resultant calvarial defect. This study examines the postoperative infection rate when bone fragments are replaced primarily. METHODS: A retrospective study was carried out of all patients admitted with the diagnosis of compound depressed skull fracture to a university hospital from 1991 to 1996. RESULTS: Of 52 patients with the diagnosis of compound depressed skull fracture treated at our university hospital over the past 5 years, 32 underwent elevation and repair within 72 hours. All patients except one received antibiotics during surgery and for at least 1.5 days after surgery. Follow-up averaged just over 22 months. In all 32 consecutive patients treated with debridement and elevation of compound depressed skull fractures with primary replacement of bone fragments within 72 hours of injury, there were no infectious sequelae. CONCLUSIONS: Immediate replacement of bone fragments in compound depressed skull fractures does not increase the risk of infectious complications.
Adolescent↗
Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates.
OBJECTIVE: A depressed skull fracture is an inward buckling of the calvarial bones and is referred to as a "ping-pong" fracture. This study aimed to look at differences between "spontaneous" and "instrument-associated" depressed skull fractures. STUDY DESIGN: This retrospective, case-control analysis included every neonate who was admitted with a depressed skull fracture between 1990 and 2000. Cases after a spontaneous vaginal delivery, elective cesarean delivery, or cesarean delivery that was performed during labor without previous instrument use were classified as "spontaneous" (n = 18 cases). Cases after a delivery in which forceps or a vacuum cup had been used either successfully or unsuccessfully were classified as "instrument-associated" (n = 50 cases). Continuous data were analyzed with 2-tailed unpaired t tests; chi 2 analysis was used for nominal data. A probability value of <.05 was considered statistically significant. RESULTS: Fifty depressed skull fractures were associated with an instrument delivery, and 18 depressed skull fractures were classified as "spontaneous." The only obstetric parameter that differed significantly between the 2 groups was the length of the active phase. Among the 68 neonates, 15 neonates underwent prolonged second stage, forceps or manual head rotation, or forceps use during elective cesarean delivery. All "instrument-associated" cases were caused by forceps application or sequential instrument use; depressed skull fractures never occurred after isolated vacuum extraction. Every type of forceps was involved. Intracranial lesions were significantly more frequent in the instrument-associated group (30% vs 0%; P = .02). Two infants sustained persistent severe motor disabilities. CONCLUSION: Depressed skull fractures occur in the setting of spontaneous and operative deliveries, although the incidence is higher in the latter case. Depressed skull fractures that are associated with instrumental deliveries are significantly more likely to be associated with intracranial lesions. Persistent disabilities are rare.
Birth Injuries↗
Growing skull fractures (craniocerebral erosion).
The incidence of growing skull fractures ranges from less than 0.05% to 1.6%. We reviewed 22 growing skull fracture patients retrospectively. There were 15 boys and seven girls ranging in age from newborn to 6 years (mean: 12.4 months) at the time of injury. Falling was the most frequent cause of injury. In total, 17 patients presented with a scalp mass. The scalp was sunken over the bone defect in three patients. Other symptoms and signs were seizure in five patients, hemiparesis in four, recurrent meningitis in one, and pulsatile exophthalmus in one. The most common location was the parietal region. The extent of dural defect was always greater than that of bony defect, except in one case that had been previously shunted for hydrocephalus. In another patient with a growing fracture in the posterior cranial fossa, the dural edges could not be exposed, although a wide craniotomy was performed. Therefore, a cystoperitoneal shunt was inserted. Gliotic tissue was present in all the patients. Cyst or cystic lesions were observed in only nine patients, duraplasty was performed in 21, 16 were neurologically intact, and six had minor deficits. All patients under the age of 3 years with a diastatic skull fracture should be closely followed up. A sustaining diastatic fracture and brain herniation through the skull defect shown on CT or MRI imply a growing skull fracture.
Arachnoid Cysts↗