Surgical technique for ‘ping pong’ fractures: Elevation of depressed skull fractures in neonates with no burr hole

Abstract

Aim: Depressed skull fracture is a neurosurgical emergency. Surgical treatment usually requires a sizeable scalp incision and burr hole with or without craniotomy for reduction. However, depressed skull fracture in neonates, or 'ping pong' fracture, is an uncommon clinical condition, occurring in approximately 4-10 in 100 000 live births. No standard treatment is established for depressed skull fracture in neonates. With a minimally-invasive technique, a good surgical outcome can be achieved with minimal blood loss and no bone loss. Patients and Methods: A full-term, neonatal girl presented with spontaneous 'ping pong' fracture after a smooth, normal vaginal delivery. The anterior fontanelle was full. Computed tomography of the brain showed right parietal depressed skull fracture with sulci effacement, obliteration of the lateral ventricle and midline shift. Skull fracture reduction was performed with the bone elevation technique via access to the coronal suture without a burr hole or craniotomy. Results: A small stab wound incision was made over the right coronal suture at the lateral edge of the anterior fontanelle. This site was in close proximity to the anterior margin of the depressed skull fracture. With access to the coronal suture and dissection in the epidural space, reduction was achieved intraoperatively by elevation of the inner table of the skull bone. Blood loss was minimal, and there was no bone loss. The clinical outcome was excellent at 1-week, 3-months', 1-year and 18-months' follow up. Conclusion: For neonatal depressed skull fractures with clinical and radiographic evidence of a mass effect requiring surgical intervention, elevation with no burr hole is a good technique for bone reduction with minimal blood loss and no bone loss.