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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 61
| Issue : 5 | Page : 497-500 |
Early diagnosis and treatment of growing skull fracture
Xiaoyu Wang, Guoping Li, Qiang Li, Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| Date of Submission | 01-Jul-2013 |
| Date of Decision | 16-Aug-2013 |
| Date of Acceptance | 11-Oct-2013 |
| Date of Web Publication | 22-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
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.121918
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 |
| » Introduction | |  |
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 | | |
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
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| » Results | | |
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].
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)
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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 | | |
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.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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