Intra-uterine fracture of the infant's skull

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.

[Depressed skull fractures in newborns. Case report of ping-pong fracture and literature review]

Depressed skull fractures (ping-pong) in the fetus and newborn are associated with birth canal pathology, maternal trauma and birth trauma following instrumental delivery. The authors report a newborn with a depressed skull fracture (ping-pong) who underwent minimally invasive neurosurgical lifting of bone fragment through a burr hole. Strategy and methods of treatment of similar depressed skull fractures were comprehensively discussed. Moreover, the authors proposed a brief algorithm for the use of vacuum systems and various surgical techniques, including follow-up depending on type, cause, size of the fracture and concomitant intracranial lesions.

Congenital skull indentation: a case report and review of the literature

Congenital depressions of the skull are rare in Western countries. The majority relate to obstetric trauma at delivery. We present a case of a congenital depression of a neonate's skull not relating to obstetric trauma. The child had an ovoid indentation behind the right coronal suture in the temperoparietal region. This skull depression was thought to relate to the position of her right hand in utero. We report her management, neuro-imaging and outcome on follow-up. A literature review is given in brief.

Spontaneous resolution of atraumatic intrauterine ping-pong fractures in newborns delivered by cesarean section

Two cases of spontaneous intrauterine ping-pong fractures are reported in newborns delivered by cesarean section. Skull fractures occurred with no evidence of extrinsic trauma or cephalopelvic disproportion. Subsequent clinical follow-up at 6 and 12 months revealed normal skull reshaping and growth, with no associated neurological deficits. Spontaneous intrauterine ping-pong fractures in newborns delivered by cesarean section is a distinctly rare condition. These 2 cases demonstrate that, even without complicated spontaneous vaginal delivery or history of external trauma, congenital ping-pong fracture of the skull can occur. The existence of this clinical condition and its spontaneous resolution is important knowledge that can assist in the prepartum and postpartum management of children with this pathology.

Prenatal diagnosis and management of intrauterine fracture

Intrauterine fracture is an extremely rare finding, but can occur as the result of maternal trauma, osteogenesis imperfecta (OI), or theoretically other metabolic/structural abnormalities. Increased clinical awareness of the diagnosis and optimal management of these cases can lead to more positive outcomes for the patient and her child. Blunt abdominal trauma late in gestation increases the risk of fetal skull fracture, while a known diagnosis of OI or other abnormalities leading to decreased fetal bone density creates concern for long bone fracture. Biochemical and genetic tests can aid in the prenatal diagnosis of OI, while ultrasound is the best overall imaging modality for identifying fetal fracture of any etiology. When fetal fracture is diagnosed radiologically, specific management is recommended to promote optimal outcomes for mother and fetus, with special consideration given to the mother with OI. With the exception of fetal fractures due to lethal conditions, cesarean delivery is recommended in most cases, especially when fetal or maternal well-being cannot be assured. When a patient presents with risk factors for intrauterine fracture, careful evaluation via thorough history-taking, ultrasonography of the entire fetal skeleton, and laboratory tests should be performed. Heightened awareness of intrauterine fracture allows better postpartum management, whether for simple fracture care or for long-term care of patients with OI or genetic/metabolic abnormalities.

TARGET AUDIENCE

Obstetricians & Gynecologist, Family Physicians.

LEARNING OBJECTIVES

After completion of this educational activity, the reader will be able to compare x-ray, ultrasound modalities and MRI and their utility in diagnosing fetal fracture. Formulate a differential diagnosis for fetal fracture. Propose a delivery plan for a patient whose fetus has a prenatally diagnosed fetal fracture.

Intrauterine head stab wound injury resulting in a growing skull fracture: a case report and literature review

INTRODUCTION

Penetrating injuries of the gravid uterus are rare complications of pregnancy with gunshot wounds most common than stab wounds. Fetal head injury is an unusual sequela of these penetrating traumas.

MATERIALS AND METHODS

We describe the case of a 20-year-old pregnant woman stabbed at the lower abdomen at 30th weeks of gestation. She was nonsurgically managed by serial examination and continuous fetal monitoring.

RESULTS

Spontaneous vaginal delivery occurred at term with good maternal and fetal outcome. The newborn examination revealed a right temporal swelling interpreted as a subcutaneous hemangioma. At 2 years and 6 months of life, the child was led to our attention with a pulsating bulge in the right temporal region. Clinical examination and imaging were indicative of a typical growing skull fracture. The child underwent neurosurgical procedure for repairing of the dural tear and bone defect according to the senior author's personal technique, described in details, with a good neurological and esthetic outcome.

CONCLUSION

Thirty-two cases of stab wounds to the pregnant uterus have been reported to date in medical literature with two cases of fetal head injury.Growing skull fractures are rare complications of head injury and only one case has been described in the perinatal period following blunt trauma to the mother's abdomen 2-3 weeks before birth.

Fatal birth trauma due to an undiagnosed abdominal teratoma: case report and review of the literature

The fetus is subjected to mechanical forces during labor and delivery, which may result in traumatic injuries. Such injuries include intracranial hemorrhage, spinal cord lesions, cephalhematoma, cranial or peripheral nerve palsies, intraabdominal organ rupture, or bony fractures. Risk for perinatal trauma and mortality is increased in primigravidas, multiple gestations, abnormal presentations, maternal-fetal disproportion, oligohydramnios, forceps or vacuum extractions, and internal version maneuvers. Very-low-birth-weight neonates (<1500 g) are at high risk due to ease of deformity of the cranium. Infants with certain congenital anomalies or pathologic processes that distort normal anatomy are also at increased risk, especially when a prenatal diagnosis is lacking. The authors present a case of a term gestation neonate who sustained a cervical spine dislocation fracture of C5-7, with subtotal transection of the spinal cord and resultant paralysis. The fetus was in vertex presentation, and a manual vaginal delivery was attempted. When the infant lodged in the birth canal following a difficult delivery of the head and arms, its enlarged abdomen was palpated, and the delivery was converted to an emergent cesarean section. The infant lived for 3 days and then expired due to neurologic complications of trauma sustained during the attempted vaginal delivery. Autopsy revealed a previously undiagnosed intraabdominal immature teratoma. The pathology of teratomas, the most common neonatal tumor and occasionally implicated in cases of birth trauma, will be addressed, followed by a review of the literature concerning birth trauma.

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.

Extraction instrumentale en 2002 au sein du réseau AURORE : incidence et complications néo-natales graves

OBJECTIVES

The purpose of this study was to evaluate the incidence of forceps and vacuum application and the incidence of its related neonatal complications. This study was performed in a network of 37 maternity hospitals.

PATIENTS AND METHOD

A postal questionnaire was sent to 156 obstetricians between February and March 2003.

RESULTS

Response rate was 78%. In 2002 the operative vaginal delivery rate was 11.2% of all live births. Forceps are the primary instruments (6.3%) whereas vacuum delivery rate was 4.9%. One obstetrician never uses forceps while 38 (31%) never use vacuum. Only 29 (24%) report using both instruments frequently. During 2002 no neonatal death related to an operative vaginal delivery was reported while 145 neonatal complications were (3.2%). Major complications were one depressed skull fracture (1/4589) and 14 extensive caput succedaneum (14/4589). Minor complications were cutaneous lesions (124/4589) and facial palsy (6/4589). Vacuum delivery was associated with a significantly higher extensive caput succedaneum rate (P = 0.018) while the only depressed skull fracture observed was related to forceps use. Forceps delivery was associated with a significantly higher cutaneous lesions rate (P < 0.001).

DISCUSSION AND CONCLUSIONS

This study showed that, in 2002, operative vaginal deliveries still represent a significant amount of vaginal deliveries, a majority of obstetricians do not use both instrument and neonatal associated complications are frequent (3.2%) but rarely severe. Therefore, we believe that every method that allows a safe teaching of operative delivery should be promoted.

Pelvic fractures in pregnancy: factors influencing maternal and fetal outcomes

BACKGROUND

The purpose of this study was to determine factors influencing maternal and fetal outcomes associated with pelvic fractures in pregnancy.

METHODS

A literature review of pelvic and acetabular fractures during pregnancy was performed, providing 101 cases for analysis (1 case report was included). Factors influencing maternal and fetal mortality were evaluated.

RESULTS

Pelvic and acetabular fractures during pregnancy were associated with a high maternal (9%) and a higher fetal (35%) mortality rate. Automobile-pedestrian collisions had a trend toward a higher maternal mortality rate, and vehicular collisions had a trend toward a higher fetal mortality rate, compared with falls. Injury severity influenced both maternal and fetal outcomes. Fracture classification (simple vs. complex), fracture type (acetabular vs. pelvic), the trimester of pregnancy, and the era of literature reviewed did not influence mortality rates. When considering potential causes of fetal death, direct trauma to the uterus, placenta, or fetus was not associated with a higher fetal mortality rate, compared with maternal hemorrhage. Pelvic and acetabular fracture surgery has rarely been reported in this patient population.

CONCLUSION

Pelvic and acetabular fractures in pregnancy continue to be associated with a high fetal mortality rate. Mechanism of injury and injury severity appeared to influence mortality rates, whereas the fracture classification, the fracture type, the trimester of pregnancy, and the era of literature reviewed did not.

Radiology of nonaccidental trauma

The long-term outlook for infants subjected to nonaccidental trauma is bleak. In a retrospective study with a mean 9-year follow-up, Duhaime et al [63] noted the relationship between acute factors on presentation and the long-term outcome. Infants who were unresponsive on presentation remained vegetative or severely impaired at follow-up. Most of the infants who required intubations were severely impaired at follow-up. In those with acute seizures, 60% were severely impaired, and an equal number had moderately severe to good outcome. Less than 6 months of age at the time of insult resulted in severe disability in most infants. CT findings of diffuse hypodensity or loss of gray-white differentiation led to severe disability at follow-up. Focal areas of hypodensity or contusion had an equal probability of good outcome or severe disability. Child abuse unfortunately is prevalent in our society, and as physicians our profession requires that we help our patients. When dealing with one of our most vulnerable group of patients, it is imperative when a child with injury is examined that physicians keep in their differential child abuse. This article has provided information in regards to radiographic studies that assist a physician in diagnosing child abuse. The importance of this not only is in providing appropriate care, but far more importantly in protecting a child or his or her siblings from future abuse.

In utero skull fracture: case report

In this report the authors discuss the unique case of a 19-year-old pregnant victim of a motor vehicle crash, who did not have significant injuries but in whom a fracture of the fetal skull was diagnosed. Several traumatic intrauterine fetal skull fractures have been reported over the last 100 years. In the vast majority of episodes, severe maternal trauma involving fractures of the pelvis has been causally related to the injured infant. There has not been a previous report of a motor-vehicle-associated fetal skull fracture in the absence of maternal injury with dual good outcomes. After cesarean section necessitated by fetal distress, both the baby and the mother made an excellent recovery. This case underscores the importance of a thorough examination of every pregnant trauma victim and her infant, even when there are no detectable maternal injuries.

Craniocerebral birth trauma caused by vacuum extraction: a case of growing skull fracture as a perinatal complication

A case of growing skull fracture following birth trauma and caused by vacuum extraction is reported in order to emphasize the incidence of this peculiar head injury at the beginning of extrauterine life and to point out its relation to possible neuropsychological disturbances that may appear later in childhood. Delivery by vacuum extraction increases the incidence of perinatal injuries and consequently the incidence of neurological deficits in children. Neurosurgical repair is advocated as the appropriate treatment, with the aim not only of cosmetically correcting the lesion's typical subgaleal protuberance with cranioplasty, but also of performing a water-tight closure of the dura, enabling the cerebral cortex to "fill in" the intracerebral lesion. The surgical technique and gross pathology of the lesion are described together with radiological findings before and after surgery. Reports by other authors are reviewed in an attempt to identify the conditioning factors and pathological features of this traumatic injury to skull and brain in neonates and infants. The literature on cranial fractures associated with intracerebral lesions at this age shows a significant difference in recovery and outcome from that after similar lesions in older children.

Depressed skull fracture in a newborn successfully managed conservatively: a case report

A preterm baby was born to a multiparous mother by emergency caesarean section at 36 weeks of gestation. Apart from a depression on the right temporo-parietal region measuring 3 cm x 3 cm x 0.5 cm, no other abnormality was noted. A CT scan of the brain excluded the presence of intracranial haematoma and pressure effect on the brain. Spontaneous reduction of the fracture without any adverse neurological sequelae suggests that these fractures can be managed conservatively in some instances.

Intrauterine growing skull fracture

Growing skull fractures with development of leptomeningeal cysts are rare complications of head injuries and have not been described in the perinatal period. The case history of a newborn with bilateral parietal fractures and the formation of a leptomeningeal cyst on one side detected at birth is presented. The importance of radiographic evaluation, including skull films, computered tomography, and magnetic resonance imaging, as well as the associated subarachnoid cyst and the age of presentation are discussed.

Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma

Two hundred five consecutive cases of noncatastrophic trauma occurring during the second half of pregnancy were evaluated prospectively. Pregnancy complications as a result of trauma occurred in 18 of 205 patients (8.8%): premature labor (n = 10), placental separation (n = 5), fetal injury (n = 1), and fetal death (n = 2). Multiple regression analysis of the data base showed obstetric findings (contractions, uterine tenderness, and bleeding) on presentation to be highly associated with complications (17/88; 19.3%). In their absence complications were rare (1/117; 0.9%). Detectable fetomaternal hemorrhage was significantly more common in trauma patients (18/205) than in control subjects (2/110) (p less than 0.01), but its role in managing trauma patients was limited to detection of rare massive hemorrhage (1/205) and detection of rare hemorrhage exceeding that covered by the standard Rho (D) immune globulin dose (2/205). Fetomaternal hemorrhage need not be quantitated in patients who lack obstetric findings on presentation. Despite rare reports of delayed abruptio placentae, it is doubtful that prolonged observation (greater than 2 to 3 hours) in the hospital is necessary in patients who lack obstetric findings on initial presentation.

Intrauterine skull depression and intracranial hemorrhage in a premature infant

The authors describe a case of a premature infant born with a parietal skull depression who suffered an intraventricular hemorrhage and an ipsilateral intracerebral injury. At 21 months of life the infant's gross motor milestones were delayed and he had moderate spastic hemiplegia. Although skull depressions at birth are usually benign, they may be associated with long-term neurologic sequelae.

Congenital depression of the neonatal skull

Congenital depression of the neonatal skull has had an incidence of 0.1% (1/10 000) in our newborn population during the past 8 years. These skull depressions have two pathogenetic types: deformation without fracture and fracture accompanied by depression. The cause of skull depression being the pressure exerted by the digits and fist of the newborn on his skull has not been previously reported. The treatment of choice for selected cases is nonsurgical elevation with an obstetric vacuum extractor. A CT scan should be performed prior to this treatment to rule out intracranial complications such as hemorrhage.

Spontaneous intrauterine depressed skull fractures

A survey is made of neonatal skull depressions as a result of experience with ten neonates harboring noniatrogenic intrauterine skull fractures. Several mechanisms causing intrauterine skull depression are discussed. Diagnosis was made after delivery in all cases and was confirmed by skull radiography. Various modes of therapy are mentioned and a stepwise guideline is suggested for correction of the depression by applying CT as an adjuvant diagnostic tool.

Prenatal diagnosis--a compilation of diagnosed conditions

This article provides physicians with an up-to-date listing of 182 fetal conditions diagnosed prenatally. This information is presented in two key tables: the first an alphabetical listing of the conditions and the second a grouping of them according to disease categories. The latter table also presents the technique(s) used to establish the diagnosis, as well as pertinent references. Chromosomal abnormalities, diagnosed from amniotic fluid cell karyotypes, have not been individually tabulated in either table. Current techniques utilized for prenatal diagnosis are presented (see Comment).