Fractura craneal deprimida congénita ("fractura ping-pong") en neonatos como diagnóstico diferencial de maltrato físico / Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse

Las fracturas con hundimiento de cráneo sin una explicación clara sobre su origen orientan al traumatismo con un objeto romo y a la sospecha de maltrato infantil. En el caso de los bebés recién nacidos, su corta edad es un factor de vulnerabilidad y obliga a una exhaustiva evaluación. Ante la sospecha de maltrato infantil, resulta importante evaluar los diagnósticos diferenciales para realizar la intervención más adecuada posible. Es necesario evitar tanto intervenciones excesivas como omitir la intervención que sea necesaria. Las fracturas craneales deprimidas congénitas, descritas como "fracturas pingpong", son raras (0,3 a 2/10 000 partos). Pueden aparecer sin antecedentes traumáticos o en partos instrumentalizados. Se describe en este artículo el caso de un recién nacido con una fractura ping-pong como ejemplo de una fractura no intencional.

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse. / Fractura craneal deprimida congénita ("fractura ping-pong") en neonatos como diagnóstico diferencial de maltrato físico.

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Las fracturas con hundimiento de cráneo sin una explicación clara sobre su origen orientan al traumatismo con un objeto romo y a la sospecha de maltrato infantil. En el caso de los bebés recién nacidos, su corta edad es un factor de vulnerabilidad y obliga a una exhaustiva evaluación. Ante la sospecha de maltrato infantil, resulta importante evaluar los diagnósticos diferenciales para realizar la intervención más adecuada posible. Es necesario evitar tanto intervenciones excesivas como omitir la intervención que sea necesaria. Las fracturas craneales deprimidas congénitas, descritas como "fracturas pingpong", son raras (0,3 a 2/10 000 partos). Pueden aparecer sin antecedentes traumáticos o en partos instrumentalizados. Se describe en este artículo el caso de un recién nacido con una fractura ping-pong como ejemplo de una fractura no intencional.

Reconstruction of depressed skull fracture in school patients. Technique description.

OBJECTIVE: Depressed skull fractures are the result of trauma injuries. They are present in approximately 3% of patients who arrive to an emergency room with skull trauma. The main objective of surgical repair in depressed fractures is correction of cosmetic deformity and the prevention of infections. MATERIAL AND METHODS: A retrospective and transversal study was performed by our department between April 2016 and May 2017. Sixteen patients that underwent a craniotomy for skull trauma with depressed fracture were included in the study. The diagnosis was made by simple cranial CT scan alongside a three-dimensional reconstruction. RESULTS: Of the sixteen patients included, 5 were females (31.2%) and 11 males (68.8%). Twelve of the cases were an exposed fracture. In 7 cases, the fracture was located at parietal bone; 5 were located at frontal bone and 4 at the temporal bone. The average Glasgow coma score in the sample was 13. There were no complications nor deaths. CONCLUSIONS: The remodeling and repositioning of the autologous bone graft allow an adequate cosmetic result and it also avoids the placement of implants without increasing the costs and additional risks.

OBJETIVO: las fracturas de cráneo deprimidas son el resultado de lesiones traumáticas. Se encuentran en aproximadamente el 3% de los pacientes que se presentan en salas de emergencia con traumatismo craneal. El objetivo principal de la reparación quirúrgica en fracturas deprimidas es la corrección de la deformidad cosmética y la prevención de infecciones. PACIENTES Y MÉTODOS: se realizó un estudio retrospectivo y transversal en nuestro departamento entre abril de 2016 y mayo de 2017. Se incluyeron 16 pacientes que se sometieron a una craneotomía por traumatismo craneal y fractura deprimida. El diagnóstico se realizó mediante tomografía computarizada craneal simple con reconstrucción 3D. RESULTADOS: se incluyeron 16 pacientes, 5 casos femeninos (31,2%) y 11 masculinos (68,8%). En 12 casos se observó fractura expuesta. En 7 casos la fractura se localizó en el hueso parietal; 5 casos en el hueso frontal y 4 casos en hueso temporal. El puntaje promedio en la Escala de Coma de Glasgow fue 13. No hubo complicaciones o muertes. CONCLUSIONES: la remodelación y el reposicionamiento del injerto óseo autólogo permite un resultado cosmético adecuado evitando la colocación de implantes sin aumentar los costos y riesgos adicionales.

Rupture or traumatic dislocation of cranial suture on infants, involvement of the lambdoidal accessory bones (Wormian bones): case presentation and analysis.

BACKGROUND: Sutural or Wormian bones are accessory bones of genetic and hereditary relevance, considered as ethnic and anatomical variables. Recently, they have been related to a certain type of congenital alterations such as osteogenesis imperfecta; however, there is no description in the literature of their involvement in skull fractures in infants. CASE PRESENTATION: We present a case of a male patient aged 15 months who suffered a fall from the stairs of his home approximately 6 h before arrival in the emergency room. This fall of approximately 1 m in height and with an area of direct impact on the right occipito-parietal region with no apparent loss of consciousness. At admission, with a Glasgow of 14 for irritability with subgaleal hematoma and cranial endostosis on occipitoparietal region, no more neurological signs were present. A CT scan of the skull was performed showing an occipital-parietal discontinuity at the lambdoid suture, and the scan also showed that a displacement occurred below the thickness of the adjacent bone. In addition, radiographic evidence showed a high possibility of dural penetration and an area of adjacent hemorrhagic contusion. Due to these findings, a surgical approach was decided upon. The findings in the surgical procedure were a complete dislocation (rupture) of lambdoidal cranial suture on the occipital border of the accessory bone (Wormian bone) with dura mater tear on the rupture tracing. A craniotomy was performed with dural plasty without eventualities. Forty-eight hours after surgery, he was discharged home in a stable neurologic condition. CONCLUSIONS: The present report shows the implications of approaching this type of injury, which can be confused as a depressed skull fracture. There is no description in the literature of a sutural rupture associated with Wormian bones.

Spontaneous resolution of a 'ping-pong' fracture at birth.

'Ping-pong' fractures are depressed skull fractures in newborn infants that occur as inward buckling of the calvarial bones, forming a cup shape. These fractures are often associated with maintenance of bone continuity. These fractures may occur spontaneously during the intrauterine period or secondary to birth trauma. Currently, there is no standard protocol for the management of depressed skull fractures. Neurosurgical or non-surgical approaches may be administered depends on the severity of the fracture. Most untreated ping-pong fractures resolve spontaneously within 6 months. Therefore, it is recommended to reserve surgical elevation or non-surgical techniques for infants not demonstrating spontaneous resolution during this period. In addition, neurosurgical interventions are usually considered for cases with intracranial pathology or neurological deficits or for infants who do not respond to conservative treatment. Herein, we report a case of a newborn infant with a spontaneous intrauterine ping-pong fracture, which spontaneously resolved, without surgical or non-surgical intervention.

Dural Tears In Patients With Depressed Skull Fractures.

BACKGROUND: The presence of skull fracture in patients sustaining traumatic brain injury is an important risk factor for intracranial lesions. Assessment of integrity of dura in depressed skull fracture is of paramount importance because if dura is torn, lacerated brain matter may be present in the wound which needs proper debridement followed by water tight dural closure to prevent meningitis, cerebral abscess, and pseudomeningocoele formation. The objective of this study was to determine the frequency of dural tear in patients with depressed skull fractures. METHODS: This cross-sectional study was conducted at Department of Neurosurgery Ayub Teaching Hospital Abbottabad. All the patients of either patients above 1 year of age with depressed skull fracture were included in this study in consecutive manner. Patients were operated for skull fractures and per-operatively dura in the region of depressed skull fracture was closely observed for any dural tear. The data were collected on a predesigned pro forma. RESULTS: A total of 83 patients were included in this study out of which 57 (68.7%) were males and 26 (31.3%) were females. The age of the patients ranged from 1-50 (mean 15.71±13.49 years). Most common site of depressed skull fracture was parietal 32 (38.6%), followed by Frontal in 24 (28.9%), 21(25.3%) in temporal region, 5(6.0%) were in occipital region and only 1 (1.2%) in posterior fossa. Dural tear was present in 28 (33.7%) patients and it was absent in 55 (66.3%) of patients. CONCLUSIONS: In depressed skull fractures, there are high chances of associated traumatic dural tears which should be vigilantly managed.

Fractura craneal deprimida congénita: ¿actitud a seguir? / Congenital depressed skull fracture: The steps to follow?

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Etude epidemiologique; clinique et therapeutique des fractures embarrures du crane a propos de 72 cas dans le service de neurochirurgie du CHU Gabriel Toure

Introduction : Les fractures embarrures constituent des affections frequentes en neurochirurgie dont la gravite est liee aux lesions intracraniennes associees. Les objectifs de ce travail sont les suivants : decrire les caracteristiques epidemiologiques des fractures embarrures du crane; determiner les etiologies; decrire les signes cliniques; degager les complications et les sequelles et evaluer la prise en charge. Patients et Methodes : il s'agissait d'une etude retrospective descriptive portant sur 72 malades de janvier a decembre 2013 dans le service de neurochirurgie du CHU Gabriel Toure. La frequence etait de 14;7% avec une forte predominance masculine (93% des cas). Les jeunes de 16-25 ans etaient les plus touches soit 38;9%. Les AVP constituaient la principale etiologie avec 59;7% des cas. Le traitement neurochirurgical a ete effectue chez 25 patients soit 34;72% et la craniectomie a os perdu etait la technique la plus utilises (64% des cas operes). L'infection de la plaie a ete la complication post operatoire dominante avec 15;3%. le taux de mortalite etait de 1;39%

[Neonatal skull fracture]. / Neonatal kraniefraktur.

During the latest decades the incidence of birth traumas has decreased significantly. Even so the traumas still contribute to an increased mortality and morbidity. We present a case of spontaneous neonatal skull fracture following a normal vaginal delivery. Abnormal facial structure was seen, and the fracture was identified with an MRI. The fractures healed without neurosurgical intervention. Case reports show that even in uncomplicated vaginal deliveries skull fractures can be seen and should be suspected in children with facial abnormalities.

Fractura - hundimiento craneal congénita: una realidad obstétrica / Congenital depressed skull fracture: an obstetric reality

Las fracturas craneales congénitas tienen baja incidencia, de una etiología desconocida, generando una gran alarma respecto a la actuación obstétrica en el momento del parto. Se presenta el diagnóstico, exploración radiológica y evolución clínica de dos recién nacidos con fractura-hundimiento craneal intrauterina, uno de ellos con manejo expectante y el otro con manejo quirúrgico. Ambos con buena evolución posterior y sin secuelas neurológicas ni estéticas.

The congenital skull fractures presented a low incidence, unknown aetiology, and it causes great alarm as far as the obstetric actions to be taken at birth are concerned. This work presents the diagnosis, radiology examinations and clinical evolution of two live-born infants with an intrauterine depressed skull fracture, one with expectant management and the other with surgical management. Both neonates showed good subsequent evolution with no neurological and no aesthetic sequelae.

[A man with a skull trauma]. / Een man met een hoofdtrauma.

After suffering an accidental blow to the head during soccer, a 42-year old male presented with agitation, confused speech and variable dysphasia. CT-imaging revealed a depressed parietotemporal skull fracture with an associated epidural hematoma. The epidural hematoma was surgically evacuated. In this photo report CT- and clinical images of an impressive depressed skull fracture, with an associated linear fracture are demonstrated.

Paraperesis: a rare complication after depressed skull fracture.

Depressed skull fracture is an inward buckling of the skull bones, often because of direct blow to a small surface area of the skull with a blunt object. Monoparesis is often among its clinical presentations, but midline depressed skull fracture presenting as motor weakness of both lower limbs (Paraperesis) has not yet been reported. We report the case of 55 year old male admitted to emergency department with alleged history of hit on head by a wooden rod. He had pain, mild swelling and a small cut over scalp without any symptoms & signs of neurological deficit. On day two of admission patient developed weakness of both lower limbs. On CT scan patient had bilateral depressed skull fracture of high parietal bone on either side of midline. Patient was managed conservatively, made remarkable recovery and was discharged after 2 weeks.

Faulty fetal packing.

A male infant was born by emergency caesarean section at 34(+4) weeks for failed induction of labour. Shortly after birth a depression about the same size as the baby's fist was noted over the right parietal region. After careful consideration of the perinatal history and examination findings, the baby was diagnosed with faulty fetal packing. At 3-month follow-up, the defect had completely corrected without intervention.

Five years' experience at a single centre of craniocerebral injury from winnowing fan blades.

India, an agriculture-based country, relies heavily on indigenous farm machinery. In our study we present 31 patients with winnowing fan blade head injury, operated on at our centre between 2004 and 2008. The mechanism and nature of the injuries, operative methods, outcome and methods of prevention are discussed with special reference to the occurrence of this type of injury in the pediatric population.

[Cranial lesions due to forceps delivery]. / Lesiones craneales secundarias a parto asistido con forceps.

Deliveries with forceps or vacuum-extraction increase the incidence of perinatal craneoencephalic lesions, for which reason cesarean sections are performed more frequently. We report 3 cases of cranial lesions due to forceps deliveries, 2 with depressed skull fractures and 1 with a depressed fracture and an associated epidural hematoma. Diagnosis is made on clinical and radiological founds with CT scan or MRI. Treatment is surgical and consists of elevation of the depressed fracture and evacuation of the hematoma. The correct use of forceps is very important to avoid this kind of lesions in the newborn, especially in cases of difficult delivery.

Radiolucent hair accessories causing depressed skull fracture following blunt cranial trauma.

Pediatric neurosurgeons frequently care for children with traumatic scalp and skull injury. Foreign objects are often observed on imaging and may influence the clinician's decision-making process. The authors report on 2 cases of poorly visualized hair beads that had become embedded into the skull during blunt trauma. In both cases, skull radiography and CT scanning demonstrated depressed, comminuted fractures with poorly demonstrated spherical radiolucencies in the overlying scalp. The nature of these objects was initially unclear, and they could have represented air that entered the scalp during trauma. In one case, scalp inspection demonstrated no evidence of the bead. In the other case, a second bead was observed at the site of scalp laceration. In both cases, the beads were surgically removed, the fractures were elevated, and the patients recovered uneventfully. Radiolucent fashion accessories, such as hair beads, may be difficult to appreciate on clinical examination and may masquerade as clinically insignificant air following cranial trauma. If they are not removed, these foreign bodies may pose the risk of an infection. Pediatric neurosurgeons should consider hair accessories in the differential diagnosis of foreign bodies that may produce skull fracture following blunt trauma.

Use of resorbable collagen dural substitutes in the presence of cranial and spinal infections-report of 3 cases.

BACKGROUND: Various allografts, xenografts, and synthetic materials are used in neurosurgery to repair dural defects when primary suture closure is impossible and autologous grafts are inadequate or inaccessible. When used in contaminated or infected wounds, however, nonautologous grafts promote chronic colonization and recurring infection. Recently, several resorbable dural substitutes that are broken down biologically and replaced by autologous tissues have been introduced. These include type 1 collagen matrix (DuraGen, Integra LifeSciences, Plainsboro, NJ) and a collagen implant derived from bovine skin (Durepair, Medtronic, Inc, Minneapolis, Minn), which can be applied as sutured or sutureless onlay grafts. The safety and efficacy of this material has not been reported in the setting of wound contamination or infection. CASE DESCRIPTIONS: We present 3 cases in which these new collagen dural substitutes were successfully used to close dural defects in the presence of wound contamination and infection. In one case, a lumbar dural defect was closed with DuraGen in the presence of a subdural empyema. In the second case, maceration of the cranial dura mater from extensive compound depressed skull fractures was repaired with DuraGen in the presence of a subgaleal abscess. In the third case, a large dural defect in the setting of frontal osteomyelitis was successfully closed with sutured Durepair. In all cases appropriate antibiotic coverage was provided for the infection, and the tissues healed with excellent biologic incorporation and without evidence of further infection. CONCLUSIONS: Resorbable collagen dural grafts appear to be effective alternatives to either primary dural closure or the use of autologous-harvested tissue grafts in the setting of grossly contaminated or infected wounds.

Early predictors of unfavourable outcome in subjects with moderate head injury in the emergency department.

BACKGROUND: Subjects with moderate head injury are a particular challenge for the emergency physician. They represent a heterogeneous population of subjects with large variability in injury severity, clinical course and outcome. We aimed to determine the early predictors of outcome of subjects with moderate head injury admitted to an Emergency Department (ED) of a general hospital linked via telemedicine to the Regional Neurosurgical Centre. PATIENTS AND METHODS: We reviewed, prospectively, 12,675 subjects attending the ED of a General Hospital between 1999 and 2005 for head injury. A total of 309 cases (2.4%) with an admission Glasgow Coma Scale (GCS) 9-13 were identified as having moderate head injury. The main outcome measure was an unfavourable outcome at 6 months after injury. The predictive value of a model based on main entry variables was evaluated by logistic regression analysis. FINDINGS: 64.7% of subjects had a computed tomographic scan that was positive for intracranial injury, 16.5% needed a neurosurgical intervention, 14.6% had an unfavourable outcome at 6 months (death, permanent vegetative state, permanent severe disability). Six variables (basal skull fracture, subarachnoid haemorrhage, coagulopathy, subdural haematoma, modified Marshall category and GCS) predicted an unfavourable outcome at 6 months. This combination of variables predicts the 6-month outcome with high sensitivity (95.6%) and specificity (86.0%). INTERPRETATION: A group of selected variables proves highly accurate in the prediction of unfavourable outcome at 6 months, when applied to subjects admitted to an ED of a General Hospital with moderate head injury.