Vacuum-assisted elevation of pediatric ping-pong skull fractures: a case series and technical note

Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

PURPOSE

Depressed ("ping-pong") skull fractures can be treated by different means, including observation, non-surgical treatments, or surgical intervention. The authors describe their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate variables associated with surgical outcomes.

METHODS

The authors present a retrospective review of all ping-pong skull fractures treated with vacuum-assisted elevation at the Children's Hospital of Orange County in 2021-2022. Variables included patient age, mechanism of injury, fracture depth, bone thickness at the fracture site, and degree of elevation.

RESULTS

Seven patients underwent vacuum-assisted elevation of ping-pong fractures at the bedside without the use of anesthesia. Fractures caused by birth-related trauma were deeper than those caused by falls (p < 0.001). There was no significant difference between groups in bone thickness at the fracture site (2.10 mm vs 2.16 mm, n.s). Six of the seven patients experienced significant improvement in fracture site depression, with four displaying a complete fracture reduction and two displaying a significant reduction. The degree of fracture reduction was modestly related to the depth of fracture, with the two deepest fractures failing to achieve full reduction. Age appeared to be related to fracture reduction, with the lowest reduction observed in one of the oldest patients in this sample. No complications were observed in any patient other than temporary mild swelling at the suction site, and no re-treatment or surgery for the fractures was required.

CONCLUSION

Vacuum-assisted elevation of ping-pong skull fractures is a safe and effective noninvasive treatment option for infants that can be used under certain circumstances. The procedure can be done safely at the bedside and is a relatively quick procedure. It avoids the need for open surgical intervention, anesthesia, or hospital admission, and can lead to excellent outcomes.

Treatment of depressed skull fractures with vacuum devices in the neonatal period: A case series

PURPOSE

The management of depressed skull fractures in infants can be either conservative or surgical. This study aimed to examine the outcomes of management with a negative-pressure vacuum device on depressed skull fractures in newborns.

METHODS

Twenty-eight patients (aged 1-6 days) with simple depressed skull fractures underwent skull elevation using negative-pressure vacuum devices. A protocol for nonsurgical management was adopted for infants with such fractures between 2010 and 2023. All patients were initially evaluated with neurological examination and complementary assessments-hematological and coagulation studies, transfontanel transcranial ultrasound, skull radiography, and computed tomography scanning with three-dimensional reconstruction-according to availability and clinical needs. Gentle (negative) extraction pressure was applied with one of several devices (according to institutional availability) for a maximum duration of 60 s; this was performed as soon as possible after diagnosis, preferably within 72 h. Follow-up data, available in the clinical records, were reported.

RESULTS

All patients exhibited satisfactory elevation of the depressed bone without associated injuries, except one patient who presented with an associated cephalohematoma which prevented optimal device coupling to generate sufficient vacuum pressure for correction. Neither neurological deficits nor development of epilepsy was noted; normal neurological assessment and oral alimentation tolerance were confirmed within 24 h post procedure.

CONCLUSIONS

According to our data, ping-pong skull fracture elevation using the vacuum method is a safe and satisfactory treatment in the neonatal period. Early treatment allows for quick resolution, and in our opinion is the strategy of choice for depressed skull fractures in newborns.

Elevation of Depressed Skull Fracture in Neonates Using a Breast Pump and a Custom-Molded Flange

BACKGROUND AND IMPORTANCE

"Ping-pong fractures" (PPF) can occur in neonates and result in cosmetic deformity and local mass effect. Standard treatment involves surgical elevation of the depressed bone when the indentation is considerable or cosmetically apparent. Surgical correction of PPF subjects patients to the risks of surgery and general anesthesia. This article and corresponding video demonstrate a novel means of correcting PPF at bedside without surgery or anesthesia. We used a hospital-grade breast pump connected to a custom-fabricated flange to successfully elevate PPF in two neonates.

CLINICAL PRESENTATION

Two moderately preterm infants were noted at birth to have large parietal PPF. To avoid surgical intervention, elevation using a suction device was attempted. A hospital-grade breast pump was used to provide suction. A custom device was fabricated out of a breast pump flange and molded Coloplast Brava® protective seal rings. This device was carefully applied to the skull to exactly match the diameter of the PPF and contour of the bone. Brief (15-30 seconds) periods of suction were applied several times until the PPF was successfully elevated as documented on subsequent computed tomography scans. Both infants achieved excellent cosmetic results with no adverse effects over 24- and 9-month follow-ups, respectively.

DISCUSSION

This technique eliminates the risks of open surgical correction and corrected the PPF without general anesthesia or adverse effects to the infant. While there may be limitations due to patient age and/or location of the PPF, the use of widely available and inexpensive custom-fitted materials with a hospital grade breast pump achieves maximal efficacy without requiring higher negative pressure suction application.

CONCLUSION

Elevation of PPF can be safely achieved in some neonates using readily available equipment: a hospital-grade breast pump, flange, and moldable adherent material. This technique is reasonable to attempt in lieu of surgical elevation.

Decision-making challenge of Ping-Pong Fractures in children: systematic review of literature

Ping-pong fractures (PPF) have become less frequent and no definite predictors to determine which fractures will elevate spontaneously and which should undergo surgical treatment have not been clearly defined. Herein, the authors present a revision of the literature, in which 54 papers were included, with a total of 228 children studied. Patients who underwent surgery accounted for 30%; elevation through obstetrical vacuum or other aspiration systems was applied in 30%, spontaneous resolution occurred in 40%; in 4 patients percutaneous microscrew elevation was applied. Overall, in 96.4% of patients the outcome was favorable since we found no significant increase in the incidence of post-traumatic seizures or neurologic sequelae with no significant differences between treated patients and spontaneous elevation. Statistical analysis showed no significant differences among the different treatment methods (P=0.53). Our results suggest that simple compound PPFs without brain compression, hematomas or dural tears could benefit from conservative management. In cases of non-spontaneous resolution after 6 months, operative strategies should be performed, considering that there is no evidence of differences between vacuum elevation and surgical elevation.