The incidence of growing skull fractures ranges from less than 0.05% to 1.6%. We reviewed 22 growing skull fracture patients retrospectively. There were 15 boys and seven girls ranging in age from newborn to 6 years (mean: 12.4 months) at the time of injury. Falling was the most frequent cause of injury. In total, 17 patients presented with a scalp mass. The scalp was sunken over the bone defect in three patients. Other symptoms and signs were seizure in five patients, hemiparesis in four, recurrent meningitis in one, and pulsatile exophthalmus in one. The most common location was the parietal region. The extent of dural defect was always greater than that of bony defect, except in one case that had been previously shunted for hydrocephalus. In another patient with a growing fracture in the posterior cranial fossa, the dural edges could not be exposed, although a wide craniotomy was performed. Therefore, a cystoperitoneal shunt was inserted. Gliotic tissue was present in all the patients. Cyst or cystic lesions were observed in only nine patients, duraplasty was performed in 21, 16 were neurologically intact, and six had minor deficits. All patients under the age of 3 years with a diastatic skull fracture should be closely followed up. A sustaining diastatic fracture and brain herniation through the skull defect shown on CT or MRI imply a growing skull fracture.

Depressed skull fractures (DSFs) account for 7-10% of children admitted to hospital with a head injury and 15-25% of children with skull fractures. We reviewed the records of 530 patients operated on for DSF from January 1, 1973, to December 31, 1993. This group was made up of 357 boys (67%) and 173 girls (33%) whose ages ranged from 1 day to 16 years (mean age 6.1 years). Fall was the most common cause of injury. Of the 530 patients with DSF, 66% had compound fractures. The incidence of compound fractures increased with age. Compound fractures caused more brain lacerations (29%) than simple fractures (15.5%) did. We also classified DSFs radiologically as true, flat, or ping-pong ball fractures. Associated intracranial lesions were found to be a bad prognostic factor. There were 13 deaths (2.5%) in this series. Satisfactory results were achieved in over 95% of the patients. Compound fractures are associated with a worse outcome and a higher incidence of intracranial lesions and cortical laceration. Unilateral pupillary dilatation and an admission GCS score of 8 or less are ominous signs in regard to mortality. We also found that the deeper the depressed bone, the higher the risk of both dural tear and cortical laceration and the worse the prognosis. A conservative approach should be followed in cases of simple DSF without associated intracranial hematoma and in cases in which the bone depression is not deeper than 1 cm.