Growing skull fractures: A clinical study of 41 patients

Abstract

Growing skull fractures are rare complications of head injury, occurring almost exclusively in infants and children under the age of three. A retrospective review at our Institute yielded 41 patients with this entity over a period of 20 years (1975-1995). The age at presentation ranged from less than 1 year to 62 years, with 33 (80.5%) patients being less than 5 years of age. The cause of injury was either a fall from a height (93%) or a road traffic accident. The most common location of a growing skull fracture was either parietal or frontoparietal (56%). One patient had a posterior fossa growing skull fracture. CT scan was performed in 19 patients which demonstrated an underlying porencephalic cyst, hydrocephalus or a cyst communicating with the ventricle. In 5 children, a ventriculo-peritoneal shunt alone was performed. Twenty four patients underwent a duro- and cranioplasty while a duroplasty alone was performed in 8 patients. The material used for cranioplasty included acrylic, wire mesh, steel plates or autologous bone. Three patients died, one due to an anaesthetic complication and two as a result of postoperative meningitis. Post-operative CSF leaks occurred in 3 patients, which were managed by a lumbar drain. Six patients had local wound infection.

Vertical Gaze Palsy in a case with Growing Skull Fracture and Porencephalic Cyst

“…4,5 It is generally recommended that in the presence of increased intracranial pressure (ICP) or progressive neurological deficits, surgical modes be adopted to treat these cysts by shunt surgery with or without closure of the defect by a duro-cranioplasty. [1][2][3]5 The vertical gaze palsy alerted us to the possibility of an intracranial lesion in the present case. Subtle morphological changes in the brain have been observed in patients with infantile esotropia.…”

“…1 This growth of the fracture may cause atrophy of the underlying cerebral tissue along with the formation of a porencephalic cyst, which may extend through the skull defect into the subgaleal space, all of which may result in progressive neurological deficits. [1][2][3] We report an unusual case of a young boy harbouring a large porencephalic cyst, who was found to have vertical gaze palsy on ocular examination in the absence of other neurological signs and symptoms.…”

“…It remains controversial whether a duro-cranioplasty should be performed prophylactically in a patient such as this to prevent any future deficit, [1][2][3]5 or whether he should be kept under close monitoring and be operated only if necessary. 8,9 The role of strabismus surgery also remains controversial.…”

“…1 To date there have been eight cases reported in the literature, [1][2][3][4] but to our knowledge this is the first report in a child.…”

Variation in the use of skull radiographs by emergency physicians in young children with minor head trauma

“…10,[12][13][14] The importance of detecting isolated skull fracture arises from the fact that depressed fractures or those with large diastasis require neurosurgical evaluation and, in some cases, surgical intervention. [15][16][17][18] Controversy exists on the usefulness of skull radiographs in children less than 2 years of age with minor head trauma. Although cerebral computed tomography (CT) has become the imaging modality of choice to evaluate an intracranial injury in the ED setting, it is clear that not all young children with minor head trauma require a CT scan.…”