Growing skull fracture

SAKRA INSTITUTE OF NEUROSCIENCES
Growing skull fracture
Dr Abhishek Rai
Resident neurosurgery

Introduction
• A skull fracture is a break in one or more of the
eight bones that form the cranial portion of the
skull, usually occurring as a result of blunt force
trauma.
• Any significant blow to the head results in a
concussion, with or without loss of
consciousness.

Compound fracture
• A fracture in conjunction with an overlying
laceration that tears the epidermis and the
meninges, or runs through the paranasal
sinuses and the middle ear structures,
bringing the outside environment into
contact with the cranial cavity is called a
compound fracture.
• Compound fractures can either be clean or
contaminated.
• Compound elevated fracture : Its rare type of
skull fracture where the fractured bone is
elevated above the intact outer table of the
skull.

Types
• Cranial vault
1. Linear/ Fissure fracture
2. Depressed
3. Elevated
4. Comminuted
5. Pond fracture
6. Gutter fracture
7. Diastatic
8. Basilar
9. Growing skull fracture
10. Cranial burst fracture
• Fracture of skull base
1. Ring fracture
2. Hinge fracture
3. ACF fracture
4. MCF fracture
5. PCF fracture

Linear/Fissure fracture
• Linear skull fractures are breaks in the bone that
transverse the full thickness of the skull from the
outer to inner table.
• They are usually with no bone displacement.
• The common cause of injury is blunt force trauma
where the impact energy transferred over a wide
area of the skull.
• Not easily detectable in radiology.
• Mc type(70%)
• Line of fracture runs parallel to axis of compression

Linear fracture
• Linear skull fractures are usually of little
clinical significance unless they parallel
in close proximity or transverse a
suture, or they involve a venous sinus
groove or vascular channel.
• The resulting complications may include
suture diastasis, venous sinus
thrombosis, and epidural hematoma.
• In young children, although rare, the
possibility exists of developing a
growing skull fracture especially if the
fracture occurs in the parietal bone

Depressed fracture
• A depressed skull fracture aka
Fracture a la signature, since it
reflects the type of weapon used.
• It occurs if the fractured bone is
driven inwards to distance
equivalent to thickness of skull
table. Sometime only involve outer
table.
• Risk of post traumatic epilepsy is
15%.

Depressed fracture
• Depressed skull fractures present a high risk of increased pressure on the brain,
or a hemorrhage to the brain that crushes the delicate tissue.
• In complex depressed fractures, the dura mater is torn.
• Depressed skull fractures may require surgery to lift the bones off the brain if
they are pressing on it by making burr holes on the adjacent normal skull.

Comminuted fracture
• Spider web/Mosaic fracture
• 2 or more intersecting lines of fracture
dividing the bone into 3 or more
fragments.
• Cause : Significant force striking over
broad surface area.
• Complications of linear and depressed
fracture

Pond fracture
• Smooth concave dent resulting from in-
buckling of skull.
• Occurs in pliable skull (<4 years)
• Inner table not fractured.
• Brain and meninges are not damaged.
• Cause :
1. Obstetric fracture
2. Forcible delivery

Gutter fracture
• Part of thickness of skull is removed
to form gutter.
• Cause: Oblique bullet wound
• Associated with irregular depressed
fracture of outer table of skull.
• Dura and brain may be torn.

Diastatic fracture
• Separation of sutures due to blow on the
head with blunt weapon.
• Young children
• Mc Sagittal suture
• Widening of the sutures may be
appreciated on plain radiograph and is
better still appreciated on CT
• The following widths are considered to be
diagnostic of sutural diastasis
a. >10 mm at birth
b. >3 mm at two years
c. >2 mm at three years

Growing skull fracture
• Linear or non-linear skull fractures in children
that enlarge with time are termed growing skull
fractures.
• Growing skull fractures are rare and occur,
almost exclusively, during the first years of life.
• Also described as traumatic ventricular
cysts, craniocerebral erosions, cranial
malacia, and leptomeningeal cysts,
among others.
• They appear most frequently as soft, subgaleal
collections overlying an enlarging bony defect at
the site of a previous diastatic fracture.

History
• Howship was the first to report a patient with a growing skull fracture. In 1816,
he described a 9-month-old child in whom an enlarging defect in his parietal
bone developed after an injury. The defect was apparent within 2 weeks after
the injury and never resolved.
• The first account of the pathology of this condition was by Rokitansky in 1856.
He reported 5 month old who struck his head during a seizure and subsequently
an enlarging scalp mass developed.
• Therapeutic puncture of the mass was performed, after which meningitis
developed and the child died. At autopsy a large bone defect was found along
with an associated dural tear and injury to the underlying brain.

History
• Dyke introduced the term leptomeningeal cyst in 1937.
• Other observations have failed to confirm the central role of leptomeningeal
cysts in the pathogenesis of growing fractures.
• Penfield and Erickson described a patient with an enlarging defect at the site of
a childhood fracture. At surgery, brain, but no cyst was found in the defect.
• Tenner and Stein also described herniated brain within the ossification defects in
children with growing fractures and highlighted the importance of local brain
injury and swelling in their development.
• Rosenthal and associates found that both the dura and arachnoid had to be
opened to produce an enlarging fracture and that concomitant injury to the
brain did not increase the likelihood that a growing fracture.

History
• Many of the children described have had significant neurological deficits from
the time of their injury, there are several reports of progressive dysfunction that
develops months or years after the event.
• This has been attributed to brain injury caused by
(1) local brain herniation and consequent ischemia
(2) repetitive trauma to the exposed brain on the bone edge or by direct
concussion,
(3) physical distortion of the brain related to its displacement
• Growing fractures occur only in settings in which there is rapid brain growth or,
much less commonly, increased intracranial pressure.

Epidemiology
• They account for less than 1% of skull fractures in large pediatric series and, for
practical purposes, are never seen in adults.
• Almost all enlarging fractures are found in children younger than 3 years; two
thirds of them occur in children younger than 1 year.
• Neurological deficit more than 50% in most case series, and for the incidence of
posttraumatic seizures, which is also around 50%

Natural history
• 3 stages of development of GSF:
• Stage I : Aka Prephase : Skull fracture (linear or comminuted) with dural
laceration and herniation of brain tissue or arachnoid membrane through torn
dura.
• Stage II : Early phase. It last approx. 2 months, Bone defect is small, deformity
relatively limited, mild neurologic deficit, Entrapped tissue prevents fracture
healing.
• Stage III : Late stage, after 2 months, bone defect significantly enlarges, brain
tissue and CSF extend between bony edge of fracture through torn dura and
arachnoid

Pathophysiology
• Although the development of growing skull fractures is multifactorial, the
predominant factor in their causation is the presence of lacerated dura mater.
• The pulsatile force of the brain during its growth causes the fracture in the thin
skull to enlarge.
• This interposition of tissue prevents osteoblasts from migrating to the fracture
site and inhibiting healing.
• The resorption of the adjacent bone by the continuous pressure from tissue
herniation through the bone gap adds to the progression of the fracture line.

Pathophysiology
• The brain extrusion may be present shortly after diastatic linear fracture in
neonates and young infants resulting in focal dilation of the lateral ventricle near
the growing fracture.

Evaluation
• The typical patient with a growing fracture is
1. Being younger than 3 years
2. Has a subgaleal fluid collection overlying the fracture, (although the collection
may resolve soon after injury)
3. Has a neurological deficit caused by the injury
4. Has skull radiographs that demonstrate a diastatic fracture with at least 3.5-mm
separation of the bone edges
• Some authors have advised obtaining skull radiographs 6 weeks and again
several months after the injury while others asked to see these patients in the
clinic after 8 weeks.

Evaluation
• Common initial complaints are
1. pain at the fracture site
2. Epilepsy
3. progressive neurological deficit.
• On examination :
1. Palpable ossification defect, larger than the one initially present, that is usually
but not always overlain by a soft, often pulsatile subgaleal collection. -
Operative
2. The ossification defect is small or only minimally different than it was at initial
evaluation, and no overlying collection is present. - re-examine these children
several weeks later.

Radiology
• On plain radiographs, they appear as
smooth edged ossification defects, often
scalloped and occasionally, with sclerotic
margins.
• CT demonstrates the same bony
abnormalities and almost uniformly injury
and cystic degeneration of the underlying
brain.
• Frequently, brain tissue is seen to protrude
into the fracture; ventricular asymmetry,
with the ventricles drawn to the fracture
site, is also common.

Radiology
• MRI adds little but a clear delineation of
the parenchymal injury.
• Angiography is of minimal value in this
setting, but reported cases show vessels
outside the skull in the bone defect.

Classification
• Classification of the growing skull fractures into three types suggested here was
found to be helpful in explaining these diversities and planning the treatment

Classification
• Duro-cranioplasty was the correct treatment in type 1.
• A shunting procedure required as an initial or definitive management for type II
and III fractures with raised intracranial pressure.

Treatment
• Successful repair requires identification of the dural margin, repair of the dural
defect, and coverage of the missing bone.
• A large incision is needed; it must extend well beyond the margins of the skull
defect.
• The skin flap is reflected in the subgaleal plane and the bony defect is defined.
• The dural edge has a tendency to recede and is often located well back from the
edge of the bone.
1. It can be found by progressively removing bone from the margins of the defect
until the dura is circumferentially exposed.
2. A burr hole can be placed a few centimeters from the bone edge.

Treatment
• Circumferential craniotomy
• Once the dural defect is exposed, the underlying brain is carefully dissected. If a
large area of cortex is herniating through the dural defect, an attempt to reduce
it should be made.
• Resection of herniated gliotic tissue
• Closure of the dural defect is necessary to prevent recurrence f the growing
fracture.
• Primary closure rarely possible, so some graft material must be used.

Treatment
• Several options are available for bone coverage, the most frequently used of
which are split-thickness calvarial grafts, full thickness calvarial autografts,
synthetic materials, and split rib grafts.
• VP Shunt

Growing skull fracture

More Related Content

What's hot

Similar to Growing skull fracture

More from Abhishek Rai

Recently uploaded

Growing skull fracture

Editor's Notes