Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 23294  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,026 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

  In this Article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    PDF Downloaded136    
    Comments [Add]    
    Cited by others 8    

Recommend this journal


Table of Contents    
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 497-500

Early diagnosis and treatment of growing skull fracture

Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China

Date of Submission01-Jul-2013
Date of Decision16-Aug-2013
Date of Acceptance11-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Guoping Li
Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, Sichuan - 610041
People's Republic of China
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.121918

Rights and Permissions

 » Abstract 

Background: Growing skull fracture (GSF) is a rare complication of pediatric skull fractures and causes delayed-onset neurological deficits and cranial asymmetry. Early treatment is pivotal to prevent those complications. The aim of this study is to highlight the early diagnosis and treatment of GSFs. Materials and Methods: Between January 2000 and June 2013; 6,916 children with linear fracture were treated in three separate hospitals. Inclusion criteria were: Patients who were diagnosed and treated within 30 days and had one or more following features: (a) 3 years or less age with cephalohematoma; (b) seizures immediate to the injury; (c) underlying brain damage; and (d) bone diastasis 4 mm or more. A review was retrospectively carried out to identify those patients who had early diagnosis and surgical intervention. Results: Eighty-six patients met the inclusion criteria and all had magnetic resonance imaging (MRI) brain scans. Twenty-two patients had GSF, fall was the most frequent cause of injury and cephalohematomas the most common symptom. The most common injury site was the parietal region. Early surgical repair of dura and skull was associated with good outcomes. Conclusions: The patients aged 3 years or less with cephalohematoma, underlying brain damage, bone diastasis ≥4 mm on computed tomography (CT), and seizures immediate to the injury were high risk group for developing GSFs. Early diagnosis and surgical treatment of GSF can yield a good outcome.

Keywords: Children, diagnosis and treatment, growing skull fracture, head injury

How to cite this article:
Wang X, Li G, Li Q, You C. Early diagnosis and treatment of growing skull fracture. Neurol India 2013;61:497-500

How to cite this URL:
Wang X, Li G, Li Q, You C. Early diagnosis and treatment of growing skull fracture. Neurol India [serial online] 2013 [cited 2023 Dec 10];61:497-500. Available from:

 » Introduction Top

Growing skull fracture (GSF) is a rare complication of infant head trauma [1],[2],[3],[4] and accounts for 0.05-1.6% of all childhood fractures. [5],[6] GSFs might cause progressive widening of the fracture, herniation of the leptomeninges, and ultimately, herniation of the underlying brain parenchyma. [7],[8],[9] Left untreated, they might cause delayed-onset neurologic deficits, seizures, headache, and cranial asymmetry. For these reasons, early diagnosis and prompt management are essential. However, in many clinical scenarios, GSFs are often misdiagnosed and treated late. This is because GSFs develop a linear skull fracture, which mostly occurs in patients with a closed-head injury. Linear fracture is often neglected by both parents and physicians. [6],[7],[8],[9],[10],[11],[12] In this report, we aim to share our experience in early diagnosis and treatment of GSFs.

 » Materials and Methods Top

Between January 2000 and June 2013; 6,916 children patients with linear fracture were treated in neurosurgery departments of three large hospitals of Sichuan province of China: West China Hospital, Sichuan Provincial People's Hospital, and Chengban Branch of West China Hospital. In this study, we retrospectively reviewed these patients' data. The details of age, gender, causes of injury, symptoms and signs, radiological, and outcome were extracted and analyzed.

Inclusion criteria were: Patients who were diagnosed and treated within 30 days and had one or more of the following features: (a) 3 years or less of age with cephalohematoma; (b) seizures immediate to the injury; (c) underlying brain damage; and (d) bone diastasis 4 mm or more. All patients included in the analysis had magnetic resonance imaging (MRI) brain scan. The diagnosis of GSFs was made based on the linear fracture on computed tomography (CT) and leptomeninges cyst or brain tissue herniation through the bony defect on MRI scans. The images were assessed by two experienced neuroradiologists. Surgeries were performed once the diagnosis of GSF was confirmed. The pedicled muscle fascia flap was used for repair of the dural defects and absorbable skull lock to repair skull defect [Figure 1].
Figure 1: (a) Dural defect (arrow head), (b) pedicled muscle fascia flap repair of dural defect, (c) absorbable skull lock to repair linear skull fracture, and (d) repair of bony defect

Click here to view

 » Results Top

Eighty-six patients meet the criteria and had MRI scans, 22 (25.6%) patients were confirmed to have GSF. There were 10 girls and 12 boys. The age ranged from newborn to 4 years (mean: 8.5 months) with 20 (90.9%) patients under 3-years-old, and 15 (68.2%) patients under 1-year-old. The intervals between injury and the development of GSF ranged from 6 to 30 days (mean: 16.2 days). Fall was the most frequent cause of injury, which was seen in 16 (72.7%) patients. The other causes were birth injury (four patients) and car accidents (two patients). They are detailed in [Table 1].
Table 1: Age and type of injury of the patients

Click here to view

Of the 22 patients; 18 patients had immediate hospital admission at the time of injury, 17 had cephalohematomas over the skull fracture, and two had seizures immediate to the injury. The others four patients were admitted between 4 and 27 days after the injury. Three of the four late admitted patients presented with a pulsatile scalp mass. One patient had hemiparesis. The location of injury was parietal region in nine (40.9%) patients. The other sites were temporal (four patients), frontal (three patients), occipital (two patients), frontoparietal (one patient) temporoparietal (one patient), parietooccipital (one patient), and suboccipital (one patient). Twelve GSFs were on the left side and 10 on the right side.

All patients had CT and MRI scans. The typical finding of CT was a linear skull fracture or bone defects. Three-dimensional CT revealed enlargement of the skull fracture [Figure 2]. Bone diastasis on CT ranged from 4 to 8 mm (mean: 5.4 mm). Cephalohematomas (17 patients), encephalomalacia (eight patients), underlying brain damage (three patients), and cystic parenchymal lesions (three patients) were identified on CT. MRI scans showed underlying brain injury in all three patients. Axial T2-weighted MR image of all patients showed high signal of leptomeningeal cysts or brain tissue herniation through the fracture site [Figure 3].
Figure 2: Computed tomography scan of a 15-month-old boy, 8 days after trauma, showing bone defect. (a) Bone window (arrow head). (b) Three-dimensional CT (arrow head)

Click here to view
Figure 3: (a) T2-weighted magnetic resonance imaging axial view of a 2-year-old boy, 5 days after trauma, showing hyperintense cystic lesion herniating through the fracture (arrow head). (b) T2-weighted MRI axial view of a 2-month-old girl, 3 days after trauma, showing a zone of the same intensity as the brain contusion herniating through the fracture (arrow head)

Click here to view

All patients had an uneventful recovery during the postoperative follow-up period ranging from 12 to 37 months (mean: 23.8 months). No complications such as cerebrospinal fluid leak, hemorrhage, infection, headache, seizures, or new neurological deficit were documented. All patients showed contentment about the cosmetic results.

 » Discussion Top

GSF is well-documented, but a rare complication of head trauma in infancy and early childhood, with reported incidence from 0.05 to 1.6%. [1],[2],[3],[4],[5],[6] GSFs primarily occur in the first few years of life and if the infancy and early childhood are taken into consideration, the incidence would be higher. [7],[9],[10],[11],[12],[13],[14] Lende and Erickson reported 90% of GSFs occurring before 3 years of age and more than 50% occurred before 12 months. [15] Twenty (90.9%) of our patients were 3 years or younger, 15 (68.2%) patients were under 1 year. Fall was the most frequent cause of the injury, followed by birth injury and car accidents.

Although there was no study specifically comparing outcomes in cases of GSF with early treatment versus delayed treatment However, few studies did reveal a more favorable outcome in the early treatment group. [16],[17],[18],[19],[20],[21] In theory, early treatment might reduce the secondary insults, minimize complications, and provide the best prognosis. Liu et al., retrospectively reviewed 27 patients with GSF and concluded that the accurate diagnosis and early treatment of GSF in the first 2 months resulted in a better prognosis. [21] It has been suggested that small skull and dural defects are easier to repair in the early phase, while the encephalomalacia and progressive loss of parenchymal tissue are likely to result in irreversible complication at the late stage. [15],[16],[17],[18],[19],[20],[21],[22] In our series, all the patients also had an early diagnosis and prompt surgery with an excellent outcome. Thus, it is prudent to diagnose GSF early for good surgical outcomes.

Age is the most significant risk factor for GSF after head injury. [1],[5],[7],[8],[9],[10],[11],[12],[13],[14],[15] Head injury in the younger children is distinctively different from that of older children and adults. Because the dura of young adheres more tightly to the bone than that of older group, it is more easily torn apart when the skull fractures. [1],[13],[21] In addition, the brain and skull grow rapidly within the first 2 years of life. [3],[4],[5],[6],[7] Thus, young children with skull fracture are more prone to develop GSFs. A normal neurologic examination and stable consciousness level do not preclude the presence of GSF in young age group. There is consensus that age under 3 years is almost certainly a risk factor for GSF. [5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] Previous studies have also shown that cephalohematoma was an indirect sign of bone fracture. [3],[4],[5] Ersahin et al., stated that all of their patients with GSF had cephalohematoma. [5] Seventeen (77.3%) of our patients also presented with cephalohematoma, frequency similar to other studies.

In some anecdotal studies, other factors such as seizures immediate to the injury and brain damage underlying the skull fracture were also considered as indirect pointers of GSF. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13] Larger series of patients with GSF who underwent CT at the time of initial presentation exhibited large skull fracture, and more specifically bone diastasis of 4 mm or more. [5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Twenty-two (25.6%) patients also exhibited the diastasis of the same size and developed GSF in our series.

Based on our experience and review of the available literature, we propose that children under 3 years with cephalohematoma, underlying brain damage or bone diastasis ≥4 mm on CT, and seizures immediate to the injury are more susceptible to developing GSF. In the absence of correlative studies documenting the incidence of skull fractures in this subgroup, we recommend that all such patients should undergo CT and more importantly, MRI scan at initial presentation. CT scan is not sensitive enough to detect dural tears at the initial phase; whereas, MRI has a greater sensitivity. [23],[24],[25] In some developing countries where MRI is not readily available, some authors have suggested using B ultrasound for early detection of the dural defect, but the clinical efficacy of this approach remains to be determined. [26] In our series, all the patients had CT and MRI and these imaging modalities were proved to be effective for early diagnosis of GSF.

Furthermore, follow-up after head injury is very important to avoid misdiagnosis. Clinical follow-up over the next few weeks should be focused on the development of any fresh neurologic deficits and on evaluating the size of the scalp hematoma. Most delays in the diagnosis and management of GSFs are related to the lack of knowledge and awareness of the condition among parents and caregivers. Therefore, the place of parent education should not be underestimated or overlooked. The parents should be informed about the possibility of GSF and be instructed to watch for any persistent or progressive scalp swelling and the onset of any neurologic signs and symptoms throughout the process.

The limitations of our study are retrospective nature of the study and small number of patients. More work is needed to more accurately define the incidence and risk factors of GSF.

 » References Top

1.Abuzayed B, Tuzgen S, Canbaz B, Yuksel O, Tutunculer B, Sanus GZ. Reconstruction of growing skull fracture with in situ galeal graft duraplasty and porous polyethylene sheet. J Craniofac Surg 2009;20:1245-9.  Back to cited text no. 1
2.Caffo M, Germano A, Caruso G, Meli F, Calisto A, Tomasello F. Growing skull fracture of the posterior cranial fossa and of the orbital roof. Acta Neurochir (Wien) 2003;145:201-8.  Back to cited text no. 2
3.Crocker M, Tawari G, Robertson F, Connor S, Bassi S. Growing skull fracture in the absence of a dural tear. Br J Neurosurg 2006;20:97-9.  Back to cited text no. 3
4.Diyora B, Nayak N, Kamble H, Kukreja S, Gupte G, Sharma A. Surgical treatment and results in growing skull fracture. Neurol India 2011;59:424-8.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Ersahin Y, Gulmen V, Palali I, Mutluer S. Growing skull fractures (craniocerebral erosion). Neurosurg Rev 2000;23:139-44.  Back to cited text no. 5
6.Leung GK, Chan KH, Hung KN. Growing skull fracture in an adult nine years after blunt head trauma. J Clin Neurosci 2011;18:855-7.  Back to cited text no. 6
7.Singla N, Gupta SK. The natural history of an untreated growing skull fracture: An unusual case. Pediatr Neurosurg 2010;46:76-9.  Back to cited text no. 7
8.Vignes JR, Jeelani Nu, Dautheribes M, San-Galli F, Liguoro D. Cranioplasty for repair of a large bone defect in a growing skull fracture in children. J Craniomaxillofac Surg 2007;35:185-8.  Back to cited text no. 8
9.Ziyal IM, Aydin Y, Turkmen CS, Salas E, Kaya AR, Ozveren F. The natural history of late diagnosed or untreated growing skull fractures: Report on two cases. Acta Neurochir (Wien) 1998;140:651-4.  Back to cited text no. 9
10.Matsuura H, Omama S, Yoshida Y, Fujiwara S, Honda T, Akasaka M, et al. Use of magnetic resonance imaging to identify the edge of a dural tear in an infant with growing skull fracture: A case study. Child Nerv Syst 2012;28:1951-4.  Back to cited text no. 10
11.Ly-Ba A, Ba MC, Kabre A, Badiane M, Badiane SB, Ba-Diop S, et al. Growing skull fracture with cerebral and ventricular hernia after brain trauma. Dakar Med 2002;47:30-2.  Back to cited text no. 11
12.Mierez R, Guillen A, Brell M, Cardona E, Claramunt E, Costa JM. Growing skull fracture in childhood. Presentation of 12 cases. Neurocirugia (Astur) 2003;14:228-33.  Back to cited text no. 12
13.Singhal A, Steinbok P. Operative management of growing skull fractures: A technical note. Childs Nerv Syst 2008;24:605-7.  Back to cited text no. 13
14.Zegers B, Jira P, Willemsen M, Grotenhuis J. The growing skull fracture, a rare complication of paediatric head injury. Eur J Pediatr 2003;162:556-7.  Back to cited text no. 14
15.Lende RA, Erickson TC. Growing skull fractures of childhood. I Neurosurg 1961;18:479-89.  Back to cited text no. 15
16.Sanford RA. Prevention of growing skull fractures: Report of 2 cases. J Neurosurg Pediatr 2010;5:213-8.  Back to cited text no. 16
17.Nagata C, Katsuta T, Kenjo M, Ukaji K, Nakagaki H. Growing skullbase fracture: A case report with special reference to its pathogenesis. Brain Nerve 2007;59:1293-7.  Back to cited text no. 17
18.Vignes JR, Jeelani NU, Jeelani A, Dautheribes M, Liguoro D. Growing skull fracture after minor closed-head injury. J Pediatr 2007;151:316-8.  Back to cited text no. 18
19.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.  Back to cited text no. 19
20.Harvey K, Turner MR, Adcock J. Child neurology: A growing skull fracture. Neurology 2009;72:e38.  Back to cited text no. 20
21.Liu XS, You C, Lu M, Liu JG. Growing skull fracture stages and treatment strategy. J Neurosurg Pediatr 2012;9:670-5.  Back to cited text no. 21
22.Pezzotta S, Silvani V, Gaetani P, Spanu G, Rondini G. Growing skull fractures of childhood. Case report and review of 132 cases. J Neurosurg Sci 1985;29:129-35.  Back to cited text no. 22
23.Husson B, Pariente D, Tammam S, Zerah M. The value of MRI in the early diagnosis of growing skull fracture. Pediatr Radiol 1996;26:744-7.  Back to cited text no. 23
24.Gallo P, Mazza C, Sala F. Intrauterine head stab wound injury resulting in a growing skull fracture: A case report and literature review. Childs Nerv Syst 2010;26:377-84.  Back to cited text no. 24
25.Hamamcioglu MK, Hicdonmez T, Kilincer C, Cobanoglu S. Large intradiploic growing skull fracture of the posterior fossa. Pediatr Radiol 2006;36:68-70.  Back to cited text no. 25
[PUBMED] P Djientcheu V, Njamnshi AK, Ongolo-Zogo P, Kobela M, Rilliet B, Essomba A, et al. Growing skull fractures. Child Nerv Syst 2006;22:721-5.  Back to cited text no. 26


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

This article has been cited by
1 Pediatric Cranial Vault and Skull Base Fractures
Malia McAvoy, Richard A. Hopper, Amy Lee, Richard G. Ellenbogen, Srinivas M. Susarla
Oral and Maxillofacial Surgery Clinics of North America. 2023;
[Pubmed] | [DOI]
2 Unusual pattern of leptomeningeal cyst with herniation of porencephalic cyst
Suryansh Arora, Kavita Vani
Egyptian Journal of Radiology and Nuclear Medicine. 2023; 54(1)
[Pubmed] | [DOI]
3 Cranioplasty for a Growing Fracture of the Skull: A Case Report
Vaidehi Mendpara, Sweta Sahu, Krupaa Madhu, Sumaiya Tarannum Shaik, Manasvi Reddy Maram, Balaganesh Natarajan, Swetha Movva, Anam Sayed Mushir Ali, Dharmesh R Chauhan
Cureus. 2022;
[Pubmed] | [DOI]
4 Growing Skull Fracture of Temporal Bone in Adults: A Case Report and Literature Review
Xiao-hong Yan, Ke Qiu, Yan Gao, Jianjun Ren, Danni Cheng, Wendu Pang, Yao Song, Wen Yang, Rong Yu, Yu Zhao
Ear, Nose & Throat Journal. 2020; 99(10): 654
[Pubmed] | [DOI]
5 Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution’s Experience
Joseph Lopez, Jennifer Chen, Taylor Purvis, Alvaro Reategui, Nima Khavanin, Rajiv Iyer, Paul N. Manson, Amir H. Dorafshar, Alan R. Cohen, Richard J. Redett
Plastic & Reconstructive Surgery. 2020; 145(5): 953e
[Pubmed] | [DOI]
6 Surgical Treatment of Growing Skull Fracture: Technical Aspects of Cranial Bone Reconstruction
Ikkei Tamada, Satoshi Ihara, Yuki Hasegawa, Marie Aoki
Journal of Craniofacial Surgery. 2019; 30(1): 61
[Pubmed] | [DOI]
7 A Review of Techniques Used in the Management of Growing Skull Fractures
Noemie Vezina,Becher Al-Halabi,Hani Shash,Roy R. Dudley,Mirko S. Gilardino
Journal of Craniofacial Surgery. 2017; 28(3): 604
[Pubmed] | [DOI]
8 Growing skull fractures: Guidelines for early diagnosis and effective operative management
Reddy, D.R.
Neurology India. 2013; 61(5): 455-456


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow