Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience.

BACKGROUND: Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years. METHODS: All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort. RESULTS: Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications. CONCLUSIONS: This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Calving-related intradural avulsion injuries of the thoracolumbar spinal nerve roots in a calf.

Calving difficulty may lead to traumatic peripheral nerve injury. A male, 8-mo-old, Japanese Black calf with a history of secondary dystocia as a result of fetal gigantism had lameness and gait disturbance. At autopsy, multifocal dural thickening with adhesions to the adjacent spinal cord was observed at T12-13 and L4-5 vertebral levels. Microscopically, numerous traumatic neuroma-like fascicles of nerve twigs were embedded in the dura mater with abundant collagenous connective tissue. By immunohistochemistry, axons and Schwann cells were confirmed in each nerve fascicle. Our observations suggest that avulsion injuries in the preganglionic fibers of the spinal nerve roots, and secondary spinal cord compression, resulted in the development of neurologic signs.

Computational analysis of glenohumeral joint growth and morphology following a brachial plexus birth injury.

Children affected with brachial plexus birth injury (BPBI) undergo muscle paralysis. About 33% of affected children experience permanent osseous deformities of the glenohumeral joint. Recent evidence suggests that some cases experience restricted muscle longitudinal growth in addition to paralysis and reduced range of motion at the shoulder and elbow. It is unknown whether altered loading due to paralysis, muscle growth restriction and contracture, or static loading due to disuse is the primary driver of joint deformity after BPBI. This study uses a computational framework integrating finite element analysis and musculoskeletal modeling to examine the mechanical factors contributing to changes in bone growth and morphometry following BPBI. Simulations of 8 weeks of glenohumeral growth in a rat model of BPBI predicted that static loading of the joint is primarily responsible for joint deformation consistent with experimental measures of bone morphology, whereas dynamic loads resulted in normal bone growth. Under dynamic loading, glenoid version angle (GVA), glenoid inclination angle (GIA), and glenoid radius of curvature (GRC) (-1.3°, 38.2°, 2.5 mm respectively) were similar to the baseline values (-1.8°, -38°, 2.1 mm respectively). In the static case with unrestricted muscle growth, these measures increased in magnitude (5.2°, -48°, 3.5 mm respectively). More severe joint deformations were observed in GIA and GRC when muscle growth was restricted (GVA: 3.6°, GIA: -55°, GRC: 4.0 mm). Predicted morphology was consistent with literature reports of in vivo glenoid morphology following postganglionic BPBI. This growth model provides a framework for understanding the most influential mechanical factors driving glenohumeral deformity following BPBI.

Sagittal craniosynostosis associated with midline cephalhematoma or vice versa, case report and a review of the literature.

INTRODUCTION: Sagittal craniosynostosis associated with midline cephalhematoma is a rare finding. Despite the controversy regarding its etiopathogenesis, this condition represents a clear indication for surgery. CASE REPORT: We present a case of a 10-week-old boy with an ossified midline vertex cephalhematoma and sagittal craniosynostosis. The child underwent a cephalhematoma excision and minimally invasive non-endoscopic narrow vertex craniectomy, with calvarial vault remodeling followed by 2 weeks use of a cranial orthosis. On 5-month follow-up, mesocephaly was achieved. CONCLUSION: Our case is well documented with native CT, 3D CT, intraoperative pictures, and 3D head scan imaging. We described our minimally invasive non-endoscopic technique that led to a rapid cranial vault remodeling with reduction of cranial orthosis need. A review of literature focused on surgical techniques is included.

Newborn with a depression to her skull.

A 9 week-old female, born via normal spontaneous vaginal delivery at 40 weeks, presented to the emergency department for a depression to her left skull, first noticed 3 three weeks prior. Ping Pong Fractures should be recognized and appropriately treated by an emergency physician.

New Entity of Skull Lesions due to Birth Trauma: Kanat (Wing) Fractures.

AIM: To discuss a special type of skull lesion detected after delivery. We reviewed our experience on scalp swelling in term neonates to further investigate the relationship between cranial injuries and labor process. MATERIAL AND METHODS: A total of 55 newborns with scalp swellings were assessed with medical records retrospectively between January 2007-July 2017. A radiologist and a pediatric neurosurgeon re-analyzed all skull X-ray images via picture archiving and communication system of the hospital. RESULTS: A special type of skull fracture, called Kanat (wing) fracture, was detected. The fractures appeared unique, were located in the midline parietal bone, and were difficult to detect by X-ray. Kanat fractures accounted for 12.7% of the 55 cases (n=7). Patients without (group-1) and patients with (group-2) Kanat fractures were compared based on the head circumference of the newborns (p=0.881), fetal birth weight (p=0.20), maternal age (p=0.04), duration of second stage of labor (p=0.217), maternal body mass index (p=0.278), total labor time (p=0.922) and parity (p=0.375). No statistically significant difference between the two groups was determined for the compared parameters. CONCLUSION: The present study is the first research describing and discussing the possible effects of maternal, fetal and delivery characteristics on Kanat fractures. Designing clinical and experimental researches to enhance awareness and acknowledgement of skull injuries and labor process could improve the clinical outcome of the newborns.

Intradiploic hematoma in an infant: case report and literature review.

Intradiploic hematoma is extremely rare, especially in infant patients. Less than 15 cases were reported in English literature up to now. Here, we presented another intradiploic hematoma in an infant boy without coagulopathy. A left parietal craniotomy was performed. Post-operative CT showed well-reconstructed skull.

[Hepatic hematoma in neonates: about a case]. / Hématome hépatique néonatal: à propos d'un cas.

Hepatic hematoma is a condition of unrecognized origin which can become extremely serious and whose diagnosis is often made during perinatal autopsy. It is often characterised by nonspecific clinical manifestations and a long delay before biological presentation.The diagnosis is essentially based on ultrasound and treatment is often conservative.We here report a case of a full-term newborn with asymptomatic hepatic haematoma due to obstetrical trauma.

Craniocerebral birth injuries in term newborn infants: a retrospective series.

OBJECTIVE: In an attempt to further define the spectrum of cranial birth injuries, we analyzed 21 consecutive cranial birth injuries in term neonates presenting to the neurosurgical department of our institution over the period 1994-2015. METHODS: We performed a retrospective chart review from the medical records of the University Hospitals of the KU Leuven, from 1994 to 2015. We included 21 infants of 36-week gestational age or older with a diagnosis of cranial birth injury. The types and locations of injuries, the presenting signs, symptoms and their timing, and the required treatment(s) were recorded. Various maternal and neonatal factors and the mode of delivery were recorded. We recorded the different modes of delivery rates at our institution in the year 2013 and the rates in the Flemish community between 1995 and 2013, in order to compare the mode of delivery rates in the study group with current practice at our institution and with general practice over the years in the Flemish community. RESULTS: The most common clinical presentations were swelling (43% of cases) and seizures (19% of cases). Average Apgar scores were 6.57 at 1 min and 8.43 at 5 min; 48% of children had abnormally low Apgar scores at 1 min and 9.5% had abnormally low scores at 5 min. The most common intracranial lesion was skull fractures (33%). Operative treatment was required in 11 infants (52%). One infant died. Assisted mechanical delivery by either forceps and/or vacuum extraction occurred in 43% of infants. In comparison, in the year 2013, only 13.97% of deliveries at our institution were mechanically assisted. Over the period 1995-2013, the highest mechanically assisted delivery rates in the Flemish community were 14.1% in 1996. CONCLUSION: Although our series is too small to make firm conclusions, it is remarkable that the rates of assisted mechanical deliveries in our series far exceeded the assisted mechanical delivery rates at our institution in the year 2013 and even the highest vacuum and forceps delivery rates in the Flemish community over the period 1995-2013.

Exploring the dynamics of progenitor cells in the urethra after simulated birth trauma in mice.

OBJECTIVE: To examine the alteration in the cellular dynamics of the urethral tissue after a simulated birth trauma in a mouse model. MATERIALS AND METHODS: A total of 36 B6 mice received vaginal distention treatment, and four untreated mice were used as controls. Specimens were collected every 24 hours after the injury for 9 consecutive days and examined using immunofluorescent staining for cell markers including c-kit, smooth muscle actin (SMA), and vimentin. Confocal microscopy was used to localize the stained cells and determine the cell number. RESULTS: The number of c-kit positive cells increased after the 1st day and peaked on the 3rd day. The amount of SMA positive cells rapidly reduced to its lowest count on the 1st day and maintained a statistically significant low cell number than that at the basal level for 4 days after vaginal distension. The cell number finally returned to basal level on the 9th day. The amount of vimentin positive cells increased dramatically after the 1st day and plateaued from the 3rd day to the 9th day. The number of vimentin positive cells in the plateau phase was significantly higher than that of the control group. CONCLUSION: Our study confirmed that the dynamic change in different cell types after the urethral injury was dependent on the nature and physiology of the wound repairing cells during the tissue healing process. It might be a simple animal model to study birth trauma repair; however, the varied progenitor cell activity in different species should also be considered.

Three dimensionality of gleno-humeral deformities in obstetrical brachial plexus palsy.

The primary objective of this study was to test the hypothesis that gleno-humeral deformity in children and adolescent with obstetrical brachial plexus palsy is three-dimensional (3D). The study also compared the metrological properties of typical two-dimensional gleno-humeral measures to the newly developed 3D measures. Thirteen individuals (age = 11.8 ± 3.3 years) with obstetrical brachial plexus palsy participated in this IRB-approved study. 3D axial magnetic resonance images were acquired for both shoulders. Glenoid and humeral models were created in order to quantify 3D glenoid version, humeral head migration, and glenoid concavity. Two-dimensional (2D) measures were acquired as recommended in the literature. All measures were completed by two observers in this observer-blind study. Compared to the non-involved side, the glenoid was more retroverted (7.91°, p = 0.003) and inferiorly oriented (7.28°, p = 0.009). The humeral head was migrated more posteriorly (5.54 mm, p = 0.007), inferiorly (-3.96 mm, p = 0.013), and medially (-3.63 mm,p = 0.002). Eleven of the 13 glenoids were concave, based on the 3D glenoid models. The concurrent validity between three- and 2D measures were highly dependent of the parameter measured, the slice level used for the 2D analysis, and the presence/absence of pathology (0.63 < r < 0.91). The standard error of measurement for the 2D anterior-posterior version (>3°) was larger than that for the 3D measure of version (<1°) on the involved side. This study clearly demonstrated that the gleno-humeral deformation in obstetrical brachial plexus palsy is 3D, emphasizing the need for 3D subject specific gleno-humeral shape analysis for follow-up and treatment plans in children with obstetrical brachial plexus palsy.

Forceps-induced birth injury to the cornea.

A 72-year-old man was referred for cataract surgery in the right eye. On slit-lamp biomicroscopy he was noted to have a vertical split in the Descemet's membrane in the left cornea. Based on the appearance, orientation of the split and medical history of forceps delivery, a forceps injury to the left cornea was diagnosed. The break in Descemet's membrane is characteristically vertical due to the horizontal stretching of the globe which occurs with vertical compression of the globe between the orbit and the blade of the obstetric forceps. Forceps injuries are usually unilateral and affect the left eye as the most common fetal head position is left occiput anterior. In the immediate postpartum period the rupture in the Descemet's membrane leads to corneal oedema which eventually disappears leaving the visible edges of the break. This injury also leads to severe left eye astigmatism and secondary amblyopia.

Fault and blame, insults to the perinatal brain may be remote from time of birth.

There is a certainty in malpractice cases that neurodevelopmental deficits are caused by preventable events at birth when the onset, nature, and timing of the insult in the antenatal and natal period are unknown. The biggest problem is determining timing. Electronic fetal monitoring is given excessive importance in legal cases. Before assigning fault on events at birth, a better understanding of developmental neurobiology and limitations of the present clinical biomarkers is warranted. The issues of single versus repeated episodes, timing of antenatal insults, pros and cons of legal arguments, interaction of various etiologic and anatomic factors are discussed.

The role of muscle imbalance in the pathogenesis of shoulder contracture after neonatal brachial plexus palsy: a study in a rat model.

BACKGROUND: An internal rotation contracture of the shoulder is common after neonatal brachial plexus injuries due to subscapularis shortening and atrophy. It has been explained by 2 theories: muscle denervation and muscle imbalance between the internal and external rotators of the shoulder. The goal of this study was to test the hypothesis that muscle imbalance alone could cause subscapularis changes and shoulder contracture. MATERIALS AND METHODS: We performed selective neurectomy of the suprascapular nerve in 15 newborn rats to denervate only the supraspinatus and the infraspinatus muscles, leaving the subscapularis muscle intact. After 4 weeks, passive shoulder external rotation was measured and a 7.2-T magnetic resonance imaging scan of the shoulders was used to determine changes in the infraspinatus and subscapularis muscles. The subscapularis muscle was weighed to determine the degree of mass loss. An additional group of 10 newborn rats was evaluated to determine the sectional muscle fiber size and muscle area of fibrosis by use of images from type I collagen immunostaining. RESULTS: There was a significant decrease in passive shoulder external rotation, with a mean loss of 66°; in the thickness of the denervated infraspinatus, with a mean loss of 40%; and in the thickness and weight of the non-denervated subscapularis, with mean losses of 28% and 25%, respectively. No differences were found in subscapularis muscle fiber size and area of fibrosis between shoulders after suprascapular nerve injury. CONCLUSIONS: Our study supports the theory that shoulder muscle imbalance is a cause of shoulder contracture in patients with neonatal brachial plexus palsy.

Neonatal scalp haematoma and necrosis.

Birth trauma after prolonged deliveries and instrument-assisted extractions can result in skin lesions and reduced viability of the scalp. In these instances, scalp swellings and haematomas are often also seen. The classification and inter-relationship between these conditions might not, however, always be clear. This report describes three cases of neonates with scalp swellings and necrosis. Nomenclature, underlying causes, work up, treatment options, and outcomes are presented and discussed. The first case consisted of a newborn with a subgaleal haematoma and occipital pressure necrosis that healed by secondary intention. In the second case, an infected scalp haematoma led to scarring and alopecia that required secondary reconstruction with tissue expansion. The third neonate suffered from a subgaleal haematoma and a scalp lesion that required split skin grafting and secondary reconstruction with tissue expansion.

Birth-associated long-bone fractures.

OBJECTIVE: To assess the incidence and outcome of neonatal long-bone fractures at a tertiary teaching hospital. METHODS: A retrospective study of all neonates with long-bone fractures delivered at Jordan University Hospital between January 1, 2000, and December 31, 2010. RESULTS: Among a total of 34 519 live births, 8 neonates had a long-bone fracture (incidence 0.23/1000 live births); of these, 6 had a femur fracture (0.17/1000 live births) and 2 had a humerus fracture (0.05/1000 live births). The route of delivery was emergency cesarean delivery for 6 infants, elective cesarean delivery for 1 infant, and the vaginal route for 1 infant. The mean birth weight was 2723g. All neonates weighed more than 2200g and their gestational age was more than 35weeks, with the exception of 1 neonate born at 31weeks weighing 1500g. The mean time interval from birth to fracture diagnosis was 1.5days. All fractures healed with no residual deformity. CONCLUSION: Emergency cesarean delivery carries a higher risk of long-bone fracture than vaginal delivery. Prematurity, malpresentation, abnormal lie, and multiple pregnancies may predispose to long-bone fractures. The prognosis of birth-associated long-bone fractures is good.

Geometry of the proximal humeral articular surface in young children: a study to define normal and analyze the dysplasia due to brachial plexus birth palsy.

BACKGROUND: Little is known regarding the morphology of the proximal humerus in growing children. This study reports bilateral magnetic resonance imaging measurements in children with internal rotation contractures from birth palsy, hypothesizing that dysplasia alters normal humeral sphericity and symmetry. METHODS: We studied 25 children with unilateral internal rotation contractures (mean age, 3.7 years) for humeral shape by bilateral magnetic resonance imaging studies at the mid-glenoid level. Local radii of curvature were compared for symmetry and orientation. RESULTS: Neither side showed uniform radii (sphericity), but normal humeri showed symmetry lost in dysplasia. Internal rotation contractures were correlated with flattening of the anterior humeral head (P = .0002). All heads were flatter in the region of articular contact. The skew axis (the largest cross-sectional diameter of the proximal humerus) was collinear with the articular surface centerline in normal humeri, an alignment often lost with dysplasia, resulting in a skew axis angle. The severity of glenoid deformity correlated with progressive posterior displacement of the humeral head center (P < .0003). CONCLUSION: The normal humeral articular surface in the young child is not spherical and is flatter in the middle than at the periphery but is symmetric about its central axis. Internal rotation contractures result in loss of this symmetry with characteristic flattening of the anterior humeral head and development of a skew axis angle. CLINICAL RELEVANCE: Posterior displacement of the humeral head center of rotation beyond 50% of the calculated head radius warrants vigilance and possibly surgical intervention because there is a high likelihood for development of a pseudoglenoid.

[Age-related dynamics of structure changes in the 17th cortical area of children with perinatal affection of the nervous system].

Brain autopsy of children standing afterperinatal affection of the nervous system and healthy children without any neurological disorders (a control group) has been studied by computers morphometric methods. The age-related dynamics of structure parameters in the 17th cortical area was investigated. Correlation between increasing of cortical lamina's diameters and age of children with perinatal affection of the brain wasn't revealed. The width of IVand V cortical layers, size of neurons and their density in the cortex of children with perinatal pathology were significantly fewer than in the control group. However the density of glia including GFAP-positive astroglia in the children with prenatal pathology was higher to compare with the control group. We suggest that detected disorders are signs of nonspecific structure-functional changes in the visual cortex and follows destructive and compensatory restorative reactions.