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[An infantile skull fracture followed by the enlarging of the fracture line ("enlarging skull fracture") (author's transl)].

We experience sometimes an infantile skull fracture which is followed by the skull fracture line and bulging of the fractured area day by day after the head injury. Since John Howship reported the case of the partial absorption of the right parietal bone, arising from a blow on the head in a child aged 9 month in 1816, this phenomenon was variously described meningocele spuria, traumatic cephalohydrocele, leptomeningeal cyst, fibrosing osteitis, cerebrocranial erosion, traumatic meningocele, die wachsende Schädelfrakture, growing skull fracture, etc. So called "growing skull fracture" has generally the triad of the symptoms which are the parietal skull fracture in infancy or childhood, traumatic dural tears, and subsequent enlargement of the fractures. And it is said that the dural tear is an indispensable condition for the developing of the "growing skull fracture". But we recently had the case of a 14 day old male infant who had neither traumatic dural tear nor subdural hematoma, but the progressive enlarging of the fracture line in the left parietal bone. The authors suggest that there should be the difference between the growing skull fracture (with the dural teat) and the enlarging skull fracture (without the dural tear).

Fractures, Ununited

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.

Four cases of growing skull fracture in children are presented and the reasons for poor surgical results are analyzed. The clinical presentation, causative factors, and operative findings are discussed.

Female

[Iatrogenic evolutive skull fracture (author's transl)].

A case of growing skull fracture secondary to a maxilofacial operation is reported. Frequency, clinical symptoms, phisiopathology and treatment of growing skull fractures are reviewed and the rarity of the iatrogenic mechanism is stressed.

Child

Growing skull fracture of childhood with reference to the importance of the brain injury and its pathogenetic consideration.

It is recognized that the presence of a dural tear is essential in the development of a growing skull fracture. We present nine cases of growing skull fracture, stressing the importance of parenchymal injury beneath the skull and dural defects as pathogenic factors, and two cases which showed pathological conditions similar to those of growing skull fracture. According to our clinicla analysis, all of these cases followed head trauma in the first year of life. The area of cranial defect varied in size among the individual cases but was progressive in all instances. Convulsions were the most frequent symptom. With both radiologicla examinations and operative findings, it is recognized that dural tears and local cerebral injury are usually severe, and various localized ventricular enlargements are always found beneath the fracture. In many cases fibrous granulation was found filling in the bone defect and adhering to the contused cortex. The mechanism of the enlarged bone defect can be explained by classifying the lesions into three groups according to the type of tissue present: (1) granulation type; (2) cyst type, and (3) mixed type. Each type prevents the bone edge from spreading out, offering a suitable means to transmit mechanical pulsations of brain and cerebrospinla fluid. The formation of granulation tissue and dense scarring is an important factor in the growing skull fracture.

Brain Diseases

Basilar skull fractures in children. The incidence of CNS infection and the use of antibiotics.

Forty-six cases of basilar skull fractures in children were reviewed to determine the incidence of CNS infection following injury and the possible value of antimicrobial chemoprophylaxis. The clinical course of the children who were treated with antibiotics was compared with that of patients who received no antimicrobial therapy. Included in the study were patients with hemotympanum alone or with hemotympanum plus additional clinical or roentgenographic signs of basilar skull fracture; patients with tympanic membrane perforation without otorrhea but with blood in the auditory canal; and children with either otorrhea or rhinorrhea. Acute, delayed, or recurrent infection of the CNS did not develop in any of the patients. This study is the first of its kind presented in children. It would seem on the basis of the present series that the systematic use of antibiotic prophylaxis in children with hemotympanum following basilar skull fractures is unwarranted and that children with other signs of basilar skull fractures may have an equally small risk of meningitis following injury.

Adolescent

The spectrum of growing skull fracture in children.

The genesis and complications of the growing skull fracture in children is discussed. Four patients are presented to illustrate the common and uncommon features of growing skull fractures. The need for complete radiological evaluation as well as the timing of follow-up examinations is stressed.

Brain Diseases

[The expanding skull fracture (author's transl)].

An expanding skull fracture with exceptional extension into the frontal sinus, the orbit and the ethmoidal cells is discussed. A 12 year old boy fell down the stairs at the age of 8 years and fractured his left frontal bone with extension to the base of the skull. He was seen because of a swelling of the scalp, an intermittent orbital oedema and convulsions. At neurosurgery a large gaping fracture of the frontal bone was found and this was interposed with fibrous tissue and relatively denatured cerebral tissue. The management both neurosurgical and rhinological is discussed.

Child

Management of depressed skull fracture in the newborn.

The authors describe 3 cases of neonatal depressed skull fracture subsequent to difficult delivery, treated without surgical elevation. None of the patients developed neurological deficits, cosmetic deformity or electroencephalographic signs of epileptiform activity. Neonatal depressed skull fractures not associated with focal neurological signs may not require surgical therapy; we are not certain what the absolute criteria for operation should be.

Birth Injuries

Depressed skull fracture in the newborn. A report of 3 cases.

Three cases of depressed skull fractures in neonates are reported. Two of the fractures were related to birth trauma, but the third probably occurred antenatally. Treatment differed in all 3 cases. One baby underwent surgical elevation of the fracture, and another vacuum elevation, while the third received no treatment. We stress the fact that non-surgical elevation of depressed skull fracture may be successful and preferable to more drastic surgical procedures.

Female

Analysis of the treatment of basilar skull fractures with and without antibiotics.

The efficacy of chemoprophylaxis in the treatment of basilar skull fractures was studied in 129 patients over a 2-year period; antibiotics were found ineffective in preventing central nervous system infections, and in some cases may have proved harmful. It is suggested that a more rational approach to the treatment of basilar skull fractures includes close observation of the patient for early signs of meningitis, and if these should develop, treatment with antibiotics appropriate to the organism involved.

Ampicillin

[Experimental studies of skull fracture in the temporal region (author's transl)].

These experimental studies of skull fractures in the temporal region were carried out in co-operation the Faculty of Engineering and the Department of Neurosurgery of Tokyo University. 15 dry human skulls were statically compressed in the bitemporal direction. The results of our experiments are as follows: 1) The forces necessary to produce the first fracture (seperations of the parietotemporal suture) are between 135 kg and 385 kg. (average; 258 kg) 2) The forces necessary to produce the second fractures (true fractures) are between 195 kg and 550 kg. (average; 356.3 kg) 3) The decreases of the inner diameters of skulls from pre-examination to the first fracture are between 0.65 mm and 1.85 mm. 4) The decreases of the inner diameters of skulls from pre-examination to the second fracture are between 1.56 mm and 4.5 mm. 5) The forces necessary to reduce the inner diameters of skulls by 1 milimeter are between 85 kg/mm and 380 kg/mm. (average; 221 kg/mm) The forces necessary to produce a fracture in the temporal region are much less than the forces necessary to do so in the frontal region. In deforming the skull, it is necessary to apply much greater force to the frontal region than it is to the temporal region. The relation between the skull's age and the minimal force to produce the skull fracture is not clear from the results of these experiments. The weights of the skulls were directly related to the minimal force necessary to produce skull fractures. Breaks in the inner table preceded those of the outer table when linear fractures occurred over the compressed area. when depressed fractures formed in the same area, the outer table was broken before the inner table. When the linear fractures formed far from the same area, the outer table was broken before the inner table. From our investigations on sports injuries, those players who died after being hit by golf balls or baseballs showed the same clinical courses as in typical extradural hematoma. Plain X-ray examinations of those fataly injured players did not reveal any skull fractures. Plain X-ray examinations of fractured skulls often failed to reveal the lesion unless the bone fracture was widely separated. On the basis of the above results, it would appear that routine skull films using either anterior-posterior or lateral projections are inadequate for the diagnosis of skull fractures. We have had good results in the examination of skull fracture by using the stereo X-ray method.

Adult

Depressed skull fracture in the neonate. Report of three cases.

The authors describe three cases of neonatal depressed skull fracture that were elevated by means of an obstetrical vacuum extractor. In one case, a transparent breast pump shield replaced the metal vacuum extractor cup, permitting direct observation as the depression was elevated. Neonatal depressed skull fractures not associated with neurological signs may be safely elevated without surgery using the obstetrical vacuum extractor.

Birth Injuries

[Traumatic thrombosis of the internal carotid artery: Report of three cases due to head injury with basal skull fracture (author's transl)].

Three cases of traumatic thrombosis of the internal carotid artery due to head injury with basal skull fracture were reported. The mechanism of thrombosis, the symptomatologic characteristics and the prognosis were discussed with reference to the data in the literature. Four mechanisms by which the condition may be produced include; injury to the intrapetrous or cevernous portion of the carotid artery during basal skull fracture, injury to the point of emergence of the carotid artery from the cavernous sinus as a result of shearing strains suffered at the time of injury, a direct blow to the neck or trauma to the paratonsillar area by a foreign object carried in the mouth, and stretching of the carotid artery by heperextension and lateral flexion of the neck. Secondary symptoms due to thrombosis of the carotid artery after an interval develop most commonly from twelve to twenty four hours. The prognosis in these patients is mostly poor. Therefore, angiography should be performed immediately on any patient suspected of having this lesion and treatment should be considered.

Accidents, Traffic

Growing skull fractures of childhood. Possible mechanism of its focal ventricular dilatation.

Four cases of growing skull fracture are presented. Pneumoencephalography done on these cases showed a moderate to extensive degree of focal ventricular dilatation beneath the skull defect. An important factor, heretofore overlooked in explaining this focal ventricular enlargement, is our hypothesis that the force exerted on the particular area of the ventricular wall represents a pulsatile CSF movement damped in the region which is liable to yield to this compression wave in the absence of covering resistant dura mater. Because of the importance of early diagnosis in order to avoid possible delayed neurologic complications such as convulsive disorders, it is advisable to carry on repeated radiological examinations of the skull following fracture in this particular age group until the fracture heals by the progressive apposition of the bone on either side of the fractured line.

Arachnoid