Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse

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.

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.

[Neonatal skull fracture]

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.

[A man with a skull trauma]

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.

[Cranial lesions due to forceps delivery]

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.

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.

[Compound depressed fracture of occipital bone causing laceration of left occipital lobe and injury of superior sagittal sinus--case report]

A case of compound depressed fracture of occipital bone in 52-years old man caused by crane hook is presented. Bone fragments were depressed 40 millimetres causing blindeness and huge hemorrhage with symptoms of hemorrhagic shock. Laceration of left occipital lobe and penetration of superior sagittal sinus were treated during the operation. Primary elevation, debridement and primary bone replacement with additional covering of bone defect by bone cement were performed. Primary wound healing was achieved. Cortical blindeness subsided to the stage of contralateral homonymous hemianopia.

Persistent intracranial hypertension caused by superior sagittal sinus stenosis following depressed skull fracture. Case report and review of the literature

Intracranial hypertension caused by a compound depressed skull fracture on the posterior part of the superior sagittal sinus is a rare condition, and nonspecific symptoms and signs can delay appropriate diagnosis and treatment. The authors report on a case of intracranial hypertension that persisted despite conservative treatment, including anticoagulation therapy, which did not improve severe flow disturbance related to the venous sinus compression. Management of this rare condition is discussed and the literature is reviewed.

Posttraumatic pneumocephalus-induced bilateral oculomotor nerve palsy

Bilateral third nerve palsy often points to the involvement of its nucleus. Third nerve palsy as a result of posttraumatic nuclear involvement is an extremely rare condition. A 23-year-old man presented with a depressed skull fracture after acute head trauma and had Glasgow Coma Scale Score of 9. The diameters of the pupils were 6.5 and 7.5 mm and they were not reactive to light stimulation. There was bilateral ptosis. Computed tomography (CT) relieved bilateral perimesensephalic pneumocephalus. We suggested that bilateral oculomotor nerve paresis might develop in association with posttraumatic bilateral perimesensephalic pneumocephalus, which affected the nucleus of the third nerve.

Superior sagittal sinus thrombosis associated with raised intracranial pressure in closed head injury with depressed skull fracture

A case of delayed signs of intracranial hypertension following closed head injury with a depressed cranial fracture and superior sagittal sinus thrombosis is reported. Conservative treatment of intracranial hypertension, including just repeated lumbar puncture and oral acetazolamide, was performed. Spontaneous recanalization of the superior sagittal sinus was observed. Pathogenesis and different modalities of treatment are discussed.

Penetrating intracranial stone

Traumatic intracranial foreign objects may cause cranial hemorrhage and contusion at an early stage and epileptic seizures and infections at a later stage, leading to morbidity and mortality in children. In the present study we report a case of a traumatic intracranial stone, which is a rarely encountered foreign object in intracranial traumatic injuries.

Camel bite: an unusual type of head injury in an infant

Small children are predisposed for animal bite wounds in the craniofacial region, because the likelihood of sustaining trunk and extremity injuries increases with height. The clinical picture of animal bite wounds is highly variable. Depending on the dental anatomy of the biting animal, such wounds may range from sharp stitch wounds to extensive lacerations with or without tissue loss. The ears and nose are injured most often because of their exposed location. Nevertheless, depressed skull fractures with injury to the dura and to the brain parenchyma are extremely rare. This case presentation describes the rare case of a craniocerebral camel bite wound (Lackmann stage IV B) in a 3-year-old girl that required immediate neurosurgical management. The neurosurgical management, choice of antibiotic, postoperative treatment, and clinical course are discussed, and background information on camel bite injuries is given.

[Acute craniocerebral trauma in childhood--early use of MRI]

The purpose of the study was to evaluate the present diagnostic potential of MRI in early stage head trauma und possibly to replace CT studies in children. FLAIR-techniques consequently applied as "scout sequences" provided reliable identification of traumatic intra- and extracranial lesions yet during the first measurement in all 24 cases. Follow-up scan confirmed the initial results. The reliability of MRI in acute pediatric head trauma is underlined by the fact that CT scans were no longer necessary within in the last three years. Therefore the imaging algorithm of acute head trauma in children has changed in our institution: medium and high risk patients undergo MRI, in young infants we do US first. HR-CT is reserved for lesions of the visceral cranium. X rays are out.

An unusual cause of depressed skull fracture: case report

BACKGROUND

Camel collision accidents are a common occurrence in Saudi Arabia, with a high rate of mortality and morbidity. Isolated injuries are rare because of the nature of impact sustained by the person.

CASE DESCRIPTION

A 4-year-old child with an isolated depressed skull fracture resulting from a camel collision is described. The other occupants of the car were crushed to death. The child sustained only an impact to his head, causing a compound depressed skull fracture with localized cortical damage.

CONCLUSIONS

Camel collision accidents are a common cause of mortality and morbidity in Saudi Arabia. Isolated skull injuries are rare and result from a localized impact. This is the first report of a compound depressed skull fracture from such an incident. The extent of the problem and efforts toward prevention are described.