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J Neurosurg (Pediatrics 1) 103:69–72, 2005

Rational management of simple depressed skull fractures in infants KUN-LONG HUNG, M.D., PH.D., HUNG-TSAI LIAO, M.D., AND JING-SHAN HUANG, M.D. Departments of Pediatrics and Neurosurgery, Cathay General Hospital, Taipei, Taiwan Object. The management regimen for depressed skull fractures in infants can be conservative or surgical. The aim of this study was to provide a rational principle of management for simple depressed skull fractures in infants. Methods. A protocol of nonsurgical treatment for a simple depressed skull fracture was designed for all affected infants during the period from 1985 to 2001. Conservative management was used for those with a depressed fracture measuring less than 5 mm in depth, whereas vacuum extraction was applied for larger and deeper depressions. All of the patients were evaluated for initial results and later outcomes. Twenty-five infants suffering simple depressed skull fractures were consecutively enrolled. According to our protocol, 11 patients received conservative management by close observation only. Spontaneous restoration of the depression was observed in eight patients within a period of 1 to 6 months. For the remaining 14 patients, vacuum extraction was performed. A negative pressure of 0.3 to 0.8 kg/cm2 (mean 0.49 kg/cm2) was applied for a duration of 20 to 90 seconds (mean 43.6 seconds). All but one patient experienced complete recovery following extraction. The depressions of the four patients that were residual after initial management smoothed out with time. No neurological deficit or later epilepsy was noted in any patient. Conclusions. Nonsurgical management can be the treatment of choice for infants with simple depressed skull fractures, whereas vacuum extraction is one option for larger and deeper depressions to obtain prompt resolution and relieve major family anxiety, without taking additional risks.

KEY WORDS • depressed skull fracture • infant •

skull fracture is a special form of skull fracture. In newborns and infants, this type of lesion refers to a “ping-pong ball” or “pond” fracture, with inward buckling of the bone surface without loss of bone continuity (similar to the “green-stick” fracture of the long bones of children).8 The cause of depressed skull fractures includes various perinatal factors3 for the newborn and, postnatally, mainly head trauma.12 The management of a simple depressed skull fracture has traditionally been surgical elevation.8 In recent decades, however, argument has supported the notion of potential spontaneous elevation7,10 and the exploration of several nonsurgical treatment modalities, including digital pressure,12 the use of a breast pump,15 and the use of an obstetrical vacuum extractor.5,19 In 1985, we reported the first case of depressed skull fracture completely elevated by vacuum extraction.20 Since that time, we have often been consulted for nonsurgical intervention for depressed skull fracture among infants. A specific protocol of nonsurgical management has thus been adopted in our institution for all infants with such fractures.

D

EPRESSED

Clinical Material and Methods One year after our first experience of successful recovAbbreviations used in this paper: CT = computerized tomography; MR = magnetic resonance.

J. Neurosurg: Pediatrics / Volume 103 / July, 2005

neonate • pediatric neurosurgery

ery following vacuum-assisted elevation of a depressed skull fracture for a neonate, we also performed vacuum extraction for another 5-month-old boy; in the latter case, only partial elevation was achieved. For these two patients, a metal-head vacuum extractor was used. We then attempted to attach a transparent plastic cup (for example, a breast pump shield) for the subsequent cases that required vacuum extraction. A protocol of nonsurgical intervention was also designed for infants suffering simple depressed skull fracture. All infants with this type of fracture were evaluated through detailed neurological examinations and radiological assessments, including skull x-ray studies and, if necessary, CT scans or MR images. A nonsurgical modality was considered for the treatment of simple depressed fractures that appeared without the presence of either neurological deficits or radiological evidence of bone fragments, intracranial hemorrhage, or cerebral contusion. For infants with a minor depression (, 5 mm in depth), conservative management only was given, after which patients were followed up with close observation. For a larger depression (. 5 mm in depth and usually . 2 cm in length), vacuum extraction was used. A negative pressure of 0.3 to 0.5 kg/cm2 was applied to the affected site in the neonate and a slightly greater level of pressure was applied in the infant. Following completion of the procedure, patients were further assessed physically and radiologically to attempt to ascertain the existence of any major complications. All patients who received either treatment modality 69

K. Hung, H. Liao, and J. Huang TABLE 1 Vacuum extraction for infants with simple depressed skull fractures Vacuum Extraction Case No.

Age (mos), Sex*

Location of Depression

Size of Depression in cm (length 3 width 3 depth)

Pressure (kg/cm2)

Duration (sec)

1

0.0, F

4.0 3 4.0 3 1.5

0.4

60

complete

2 3 4 5 6 7 8 9 10 11 12 13 14

5.0, M 20.0, F 0.0, F 4.0, F 9.0, M 0.0, M 0.5, F 8.0, M 5.0, M 7.0, M 0.0, M 0.0, F 0.0, M

rt parietotemporal lt parietal lt parietal rt frontal rt parietal rt parietal rt temporal lt frontal rt parietal rt temporal lt parietal lt temporal lt temporal rt parietal

3.0 3 3.0 3 0.6 3.5 3 3.5 3 0.8 5.0 3 4.0 3 1.0 3.5 3 3.0 3 0.7 4.0 3 3.0 3 0.8 5.0 3 3.0 3 1.0 4.0 3 4.0 3 0.7 3.0 3 3.0 3 0.7 3.0 3 3.0 3 1.0 3.0 3 2.0 3 0.8 3.0 3 3.0 3 1.0 3.5 3 2.5 3 0.6 6.0 3 5.0 3 1.5

0.4 0.8 0.4 0.3 0.8 0.4 0.3 0.8 0.7 0.7 0.4 0.4 0.5

30 90 20 60 30 20 20 50 70 50 60 30 20

mildly depressed complete complete complete complete complete complete complete complete complete complete complete complete

Treatment Result (extent of resolution)

* Age 0 means at birth.

were followed up, through clinical visit or telephone inquiry, to determine the existence of possible neurological deficits or epilepsy sequelae. Results During the period from 1985 to 2001, inclusively, 25 (14 male and 11 female) infants who had a simple depressed skull fracture were referred from our pediatric and neurosurgical departments for nonsurgical intervention. The ages ranged from newborn to 20 months. The causes of the fractures included congenital factors in 11 patients and a postnatal fall in the other 14. Cranial depression was noted on the right side in 15 patients. The location of the cranial depressions included parietal (13 patients), temporal (eight patients), and frontal (two patients). One of the remaining two depressions was located over the frontotemporal area; the other was located over the parietotemporal area. According to our protocol, 11 patients were treated conservatively because their depressions were small. A skull xray study was the only radiological procedure performed. The depressed fractures resolved spontaneously in eight cases within 1 to 6 months. Residual minor depressions were noted for the other three patients 6 months after the injury, becoming less significant with time. Fourteen patients with deeper skull depressions underwent an attempted vacuum extraction (Table 1). In addition to a skull x-ray study, 10 also underwent CT scanning, which did not reveal any evidence of intracranial lesion. One neonate (Case 14) suffering from congenital skull depression due to maternal myoma underwent MR imaging before vacuum extraction to verify the absence of intracranial pathological features. For the initial two patients, a metal-head vacuum extractor was used. A transparent plastic cup (a breast pump cup) was substituted for the metal head for the other 12 patients (Fig. 1). As shown in Table 1, these 14 depressed fractures were all greater than 5 mm in depth and longer than 2 cm. The pressure of extraction applied ranged from 0.3 to 0.8 kg/cm2, with a mean of 0.49 kg/cm2. The extraction time ranged from 20 to 90 seconds 70

(mean 43.6 seconds) and was controlled under direct visualization. Mild swelling or ecchymosis was found on the scalp immediately following extraction, but it subsided within several hours. Mild residual depression was observed in one patient (Case 2), which became minimal with time. All 14 patients underwent follow-up skull x-ray studies soon after the extraction, and postprocedure CT scans were obtained in 10, which revealed no further intracranial lesions. The eldest patient in this series, a 20-month-old girl (Case 3) suffering from head injury resulting in left parietal depressed fracture, also responded well to vacuum extraction (Fig. 2). The effect of such treatment for a neonate (Case 14) suffering from the largest skull depression in this study is demonstrated in Fig. 3. None of the patients who underwent either treatment method suffered neurological deficits, epilepsy, or cosmetic problems during the followup period of 2 to 10 years. Discussion In the past, the classic recommendation for a simple de-

FIG. 1. A breast-pump cup of the type applied over the left parietal depressed lesion in a neonate and attached to an obstetric vacuum extractor (not shown) to perform vacuum extraction.


Management of depressed skull fractures in infants

FIG. 2. Case 3. This 20-month-old girl suffered a head injury resulting in the left parietal depression (A) with evidence of a depressed fracture on a skull radiograph (B, arrowhead) responded well to vacuum extraction (C). The impression of the cup is still visible.

pressed skull fracture was to surgically elevate it on the basis of concerns regarding cosmetic effect, possible underlying pathological features, and epileptogenicity.8 Several subsequent investigations have suggested, however, that surgical management of such an injury may not be mandatory. Spontaneous recovery, although rare, has been occasionally reported. In a study of 15 neonates having sustained severe head trauma, one patient experienced spontaneous recovery.10 Ross13 observed the spontaneous elevation of a skull depression in an infant within 4 hours. Loeser, et al.,7 described the spontaneous reduction of depressed skull fractures for three neonates within 1 day to 3.5 months from the time of injury. Lim, et al.,6 reported on an infant with congenital skull depression that spontaneously resolved within 6 weeks after birth. All of these reports featured mostly newborns and infants, reflecting the fact that infants’ relatively thin and flexible skull bones render them amenable to remodeling. Authors of a review have reported that spontaneous elevation of congenital depressed skull fractures oc-

FIG. 3. Case 14. Skull x-ray studies (A and B) and brain CT scans (C and D) revealing a large simple depressed fracture over the right parietal area before (A and C) and after (B and D) vacuum extraction.


curred within 1 day to 6 months of age.17 Our study of infants showed similar results. Nevertheless, little information exists to assist clinicians in accurately predicting which specific depressed fracture will be likely to recover spontaneously. It would appear reasonable to treat larger and deeper depressions more aggressively. Aggressive nonsurgical treatment modalities have included the use of either digital pressure12 or negative pressure.14,18 Raynor and Parsa12 described a 9-month-old infant whose depressed skull fracture was successfully elevated by the application of thumb pressure to the edge of the depressed skull. Shrager15 reported elevating skull depressions by using a breast pump. More recently, several authors have found the obstetrical vacuum extractor to be more effective because of its greater suction power.13–16 The use of such an extractor, however, imposes application limits because of its opaque metal head. It is not easy to determine the appropriate level and duration of the negative pressure applied for each particular case. On some occasions, a second application of negative pressure may be needed, as with the cases described by Tan18 and Beyers, et al.2 Consequently, Saunders and colleagues14 modified the method of vacuum extraction by attaching a transparent breast-pump shield to the vacuum extractor. Such an apparatus allows the operator to observe the elevation process in real time, thus providing an adequate extraction. As our study results demonstrate, the duration of negative pressure application (20–90 seconds) appeared to be substantially reduced compared with that reported in a number of previous studies (2–6 minutes).2,11,18,19 Regarding the vacuum-extraction procedure, several technical factors warrant due consideration. In our experience, the obstetric vacuum extractor is the preferred instrument because it provides patent tubing unlikely to collapse during the application of suction. Furthermore, the metal or transparent cup should be able to cover the entire depression and to attach tightly to the patient’s head without the likelihood of air leakage between the patient’s skin and the periphery of the suctioning device. No traction is needed during the suction procedure. As for the suction pressure, it appears that no definitive criteria exist. From the literature, a reasonable choice would be a negative pressure of approximately 0.2 kg/cm2 for a 1-kg premature baby14 and 0.4 to 0.6 kg/cm2 for a full-term newborn.1,2,14 For older patients, a negative pressure of 0.8 kg/cm2 was sufficient for either a 5.5-month-old19 or an 18-month-old infant.11 The suction pressure applied should be estab71

K. Hung, H. Liao, and J. Huang lished rather slowly for the neonate, but it should increase somewhat more rapidly for older infant to minimize scalp swelling.2 During the procedure, the elevation of the depression can be ascertained by direct visualization, an audible “click” sound or a “give” sensation accompanied by an instantaneous pressure release.2,5 Subsequent to extraction of the depressed fracture, local edema or redness usually follow but they mostly resolve within a period of several hours. The application of vacuum extraction seems to have age limitations. Most reports of vacuum reduction for simple skull depression featured newborns and infants, and the oldest age was 18 months.11 In this study, we experienced good reduction of a skull depression in a 20-month-old girl. We speculate that vacuum extraction may be applicable for children younger than 2 years of age. Although compound depressed skull fractures in childhood are typically associated with risks of dural laceration, intracranial hemorrhage, or concurrent infection resulting in persistent neurological deficits and posttraumatic seizures,9 the simple depressed fractures that tend to occur frequently among younger children are relatively benign. As described by Jennett, et al.,4 there was no discernible increase in posttraumatic seizure among patients whose simple depressed skull fractures were treated nonsurgically. Steinbok, et al.,16 further reported that there was no difference in outcome between children with simple depressed fractures treated surgically and nonsurgically in the aspects of seizure occurrence, neurological dysfunction, or overall cosmetic picture. They thus suggested that the nonsurgical modality be the standard treatment regimen for simple depressed fractures among pediatric patients. This suggestion appears to be quite compatible with our current principle of treatment. Furthermore, based on the safety and effectiveness of vacuum extraction for the treatment of depressed skull fractures, we proposed our new protocol of comparable management, that is, to treat more aggressively for larger and deeper depressions while retaining the conservative approach for patients with minor depressions. Our results have demonstrated the usefulness of this protocol, which can be fairly regarded as the treatment of choice for simple depressed fractures of the skull, particularly among infants. One might argue against the necessity of vacuum extraction for some depressions greater than 5 mm in depth because spontaneous recovery from such an injury may also be possible. One concern does exist, however. As some authors have hypothesized,1,7,9 a fracture depression deeper than 5 mm or greater than the local skull thickness might impinge on the infant’s cerebral cortex and elicit some localized compression therein, with resultant cerebral edema and decreased cerebral blood flow. Using vacuum extraction during the acute stage of the injury to obtain prompt restoration of the depression appears to be a viable option for infants, without imposing additional substantial risks. For older children with simple depressed skull fractures, conservative management remains the standard regimen, and surgical elevation would be considered only for individuals with a significant cosmetic defect, because vacuum extraction is not feasible for them. Conclusions We have provided a rational management protocol for 72

simple depressed skull fractures in infants. Nonsurgical modalities can be the treatment of choice for simple depressed fractures in infants. Although conservative management includes the potential effect of remodeling, vacuum extraction is another option for larger and deeper depressions in terms of attaining prompt recovery from the defect at an acute stage without additional risks. References 1. Ben-Ari Y, Merlob P, Hirsch M, Reisner SH: Congenital depression of the neonatal skull. Eur J Obstet Gynecol Reprod Biol 22:249–255, 1986 2. Beyers N, Moosa A, Bryce RL, Kent A: Depressed skull fracture in the newborn. A report of 3 cases. S Afr Med J 54: 830–832, 1978 3. Guha-Ray DK: Intrauterine spontaneous depression of fetal skull: a case report and review of literature. J Reprod Med 16: 321–324, 1976 4. Jennett B, Miller JD, Braakman R: Epilepsy after nonmissile depressed skull fracture. J Neurosurg 41:208–216, 1974 5. Kyle JW, Jenkinson D: Letter: Depressed fracture in the newborn. Br Med J 3:698, 1973 6. Lim CT, Koh MT, Sivanesaratnam V: Depressed skull fracture in a newborn successfully managed conservatively: a case report. Asia Oceania J Obstet Gynaecol 17:227–229, 1991 7. Loeser JD, Kilburn HL, Jolley T: Management of depressed skull fracture in the newborn. J Neurosurg 44:62–64, 1976 8. Matson DD: Neurosurgery of Infancy and Childhood, ed 2. Springfield, IL: Charles C Thomas, 1969, pp 934 9. Miller JD, Jennett WB: Complications of depressed skull fracture. Lancet 2:991–995, 1968 10. Natelson SE, Sayers MP: The fate of children sustaining severe head trauma during birth. Pediatrics 51:169–174, 1973 11. Paul MA, Fahner T: Closed depressed skull fracture in childhood reduced with suction cup method: case report. J Trauma 31:1551–1552, 1991 12. Raynor R, Parsa M: Nonsurgical elevation of depressed skull fracture in an infant. J Pediatr 72:262–264, 1968 13. Ross G: Spontaneous elevation of a depressed skull fracture in an infant. Case report. J Neurosurg 42:726–727, 1975 14. Saunders BS, Lazoritz S, McArtor RD, Marshall P, Bason WM: Depressed skull fracture in the neonate. Report of three cases. J Neurosurg 50:512–514, 1979 15. Schrager GO: Elevation of depressed skull fracture with a breast pump. J Pediatr 77:300–301, 1970 16. Steinbok P, Flodmark O, Martens D, Germann ET: Management of simple depressed skull fractures in children. J Neurosurg 66:506–510, 1987 17. Strong TH Jr, Feldman DB, Cooke JK, Greenspoon JS, Barton L: Congenital depression of the fetal skull. Obstet Gynecol Surv 45:284–289, 1990 18. Tan KL: Elevation of congenital depressed fractures of the skull by the vacuum extractor. Acta Paediatr Scand 63:562–564, 1974 19. Van Enk A: Reduction of pond fracture. Br Med J 2:353, 1972 (Letter) 20. Wu CM, Hung KL, Chen TH: [A case report of depressed skull fracture of the newborn treated with a vacuum extractor.] Taiwan Yi Xue Hui Za Zhi 84:270–275, 1985 (Chn)

Manuscript received July 20, 2004. Accepted in final form February 1, 2005. Address reprint requests to: Kun-Long Hung, M.D., Ph.D., Department of Pediatrics, Cathay General Hospital, 280, Sect. 4 JenAi Road, Taipei 10650, Taiwan. email: [email protected].
