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| EDITORIAL |
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| Year : 2013 | Volume
: 61
| Issue : 5 | Page : 455-456 |
Growing skull fractures: Guidelines for early diagnosis and effective operative management
D Raja Reddy
Department of Neurology, Apollo Hospital, Jubilee Hills, Hyderabad, Andhra Pradesh, India
| Date of Submission | 22-Oct-2013 |
| Date of Decision | 26-Oct-2013 |
| Date of Acceptance | 26-Oct-2013 |
| Date of Web Publication | 22-Nov-2013 |
Correspondence Address:
D Raja Reddy
Department of Neurosurgery, Apollo Hospital, Jubilee Hills, Hyderabad, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.121907
How to cite this article:
Reddy D R. Growing skull fractures: Guidelines for early diagnosis and effective operative management. Neurol India 2013;61:455-6 |
Growing skull fracture is a very rare complication following cranio-cerebral trauma, which occurs commonly in infants and young children and often is located over the calvarium. The first report on growing skull fracture was in the year 1816 by Howship and Rokitansky described its pathology in 1856 in an 8-month-old baby. [1] This entity was also known as leptomeningeal cyst, traumatic leptomeningeal cyst and cranio-cerebral erosion. In one of the largest studies reported from China in this issue of the journal of the total 6916 cases with a linear skull fracture during a 13-year period, only 22 cases developed growing skull fracture. [2] All the cases occurred in children aged between newborn and 4 years and 90.9% were below 3 years of age, half being below the age of 1 year. Firm adhesion of the dura to the skull bones and growing pulsatile brain in infancy and childhood are adduced as reasons for high incidence of growing skull fractures in this age group. The reported incidence of growing skull fractures ranges from 0.05% to 0.6% of skull fractures in children. Growing skull fractures are rarely reported in adults and some of these may have sustained injury during childhood.
The etio-pathologenesis of growing skull fractures is not fully understood but presence of diastatic linear skull fracture, dural and arachnoid disruption with cerebrospinal fluid leak and underlying contusion of the brain are invariable accompaniments. Experimental studies in pups confirmed this observation that dural and arachnoid tears are necessary for the enlargement of fractures with herniation of the brain and meninges. [3] Radiological and operative findings in late stages reveal the presence of leptomeningeal cysts, herniation of the leptomeninges and brain through the diastatic fracture, encephalomalacia, porencephaly and dilatation of ipsilateral or all the ventricles. Fall is the common mode of injury in these children and there is usually cephalhaematoma at the site of the injury and the development of growing skull fracture is heralded by either nonhealing of suture or separation of sutures with growing swelling and disfigurement. Rarer sites for growing skull fractures are posterior fossa, skull base and orbital region and underlying mechanisms however are similar. Growing skull fractures are also known to develop following inadvertent dural tears occurring during cranio-facial surgery and repair of craniosynostosis cases especially those of the sagittal suture. Progressive changes in the brain are revealed by the development of neurological deficits and seizures, if left untreated this entity is associated with significant morbidity. One of the largest series of growing skull fractures has been reported from India that details problems associated with this disease. [4] There was significant morbidity and even mortality associated with this entity in this report. The surgical treatment requires dural repair in all the cases and those neglected cases with large defects of dura and cranial bones need cranioplasty in addition and this becomes a formidable task in infants and young children. Some neglected cases with very large defects in infants and young children optimum surgical repair may not be possible. Such of those cases of growing skull fractures with porencephaly associated with or without hydrocephalus may be need shunt operation also. If the swelling is tense shunt surgery should precede definitive surgery for the growing skull fractures. Hence delayed diagnosis of this entity and improper planning of surgery would be harmful and should be avoided. It has been recognized and stressed that those children who are likely to develop growing skull fractures should be detected early and prophylactically operated. This has been the objective of Chinese study [2] reported in this journal as well as the recent literature on the subject.
Early detection of growing skull fractures necessitated staging of skull fractures so that they can be treated early. Two broad three-stage classifications have evolved one of which is based on clinical progression of the disease and the other based mostly on radiological findings. [5],[6] In the first classification, Stage I includes those potential cases before the advent of protrusion of meninges and brain. Ultrasonography via the fracture line appears to be a very sensitive and reliable method of detecting bone defect, dural tears and gyral herniation in the early stages of growing skull fractures. The high-risk groups were children with cephalhematoma at the time of injury, linear skull fracture wider than 4 mm, and aged less than 3 years with epileptic seizure. Eight-six children fulfilled these criteria in the Chinese study and 22 of them developed growing skull fractures later. Stage 2 consists of cases wherein the swelling has started, but it was less than 2 months old. Stage 3 is a late phase where gross swelling and neurological defects are obvious. The surgical results were good in Stage 1 and 2 and obviously poor in Stage 3. The other classification also graded the cases in to three types: Type I had a leptomeningeal cyst; Type II had encephalomalacic brain and Type III had a porencephalic cyst, which reached subgaleal space. It is obvious that the results of treatment are good in Types I and poor in other types.
Once preventive surgery is decided upon it is necessary to plan the type of surgery that is adequate and effective. Water tight dural closure is necessary in every case and in infants that alone may suffice and cranioplasty may not be necessary even if there is bone gap. Pericranial graft alone will be useful in this regard. Cranioplasty needs planning and wherever possible split cranial bone grafts are preferred. Only in neglected cases with large defects autologous rib bone grafts or methlmetacrylate or other similar types of material may become necessary to cover bony defect. To summarize every linear skull fracture case especially those in infants and children must be followed-up and any case with non-healing or widening fracture e site should be investigated and should be operated.
| » References | |  |
| 1. | Lende RA, Erickson TC. Growing skull fractures of childhood. J Neurosurg 1961;18:479-89. 
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| 2. | Wang X, Li G, Lan Z, You C. Early diagnosis and treatment of growing skull fracture. Neurol India 2013;xxxx:???.
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| 3. | Goldstein F, Sakoda T, Kepes JJ, Kavidson K, Brackett CE. Enlarging skull fractures: An experimental study. J Neurosurg 1967;27:541-50.
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| 4. | Gupta SK, Reddy NM, Khosla VK, Mathuriya SN, Shama BS, Pathak A, et al. Growing skull fractures: A clinical study of 41 patients. Acta Neurochir (Wien) 1997;139:928-32.
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| 5. | Liu XS, You C, Lu M, Liu JG. Growing skull fracture stages and treatment strategy. J Neurosurg Pediatr 2012;9:670-5.
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| 6. | Naim-Ur-Rahman, Jamjoom Z, Jamjoom A, Murshid WR. Growing skull fractures: Classification and management. Br J Neurosurg 1994;8:667-79.
[PUBMED] |
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