The growing skull fracture, a rare complication of paediatric head injury.

Abstract

Linear skull fractures in young children occasionally result in growing skull fractures. Neurosurgical correction of growing skull fractures (GSFs) by dural repair with cranioplasty is considered a safe and effective treatment with good prognosis. A 3-month-old boy fell from the stairs head first on to the floor. Initially he did not show any neurological symptoms. Craniography revealed a linear fracture of the right occipito-parietal skull bone. Cranial computer tomography showed a right-sided subdural haemorrhage, expanding beneath the fracture site, as well as contusion and swelling of the right hemisphere, leading to a modest midline shift. He was transferred to the paediatric intensive care unit for further evaluation and observation. After admission, he gradually lost consciousness and developed right-sided fixated eyes. Lowest EMV-scores were 1–4-T. Intracranial pressure, measured by an intraventricular probe, remained normal. Conservative treatment was chosen for the intracranial haemorrhage, and artificial ventilation and sedation was needed for 3 days. He developed a paresis and temporary focal epileptic activity of the left arm. This resolved over the months after discharge. Physical examination at 10 months of age (7 months after discharge) however revealed a soft pulsatile mass on the right occipito-parietal scalp. Bone ridges were felt around a discontinuum of the skull bone. Plain craniography showed a large occipito-parietal skull defect. Cerebral cranial magnetic resonance imaging revealed a cystic encephalomalacia, dilatation of the right ventricle and modest herniation of brain tissue into the skull defect (Fig. 1). Operative correction with both dural repair to resolve the herniation and cranioplasty to cover the dura and skull defect was performed. During surgery, the bone defect appeared to be covered with tissue which was later microscopically determined as granulation tissue. A dural cranioplasty with pericranium and alloplastic bone reconstruction with methacrylic resin (Palacos) was used. Four days post-surgery the patient was discharged in good general condition. GSFs are rare complications of linear skull fractures. Estimated incidence is 0.05%–1% of all skull fractures [2,3,4]. Most GSFs occur in the first 3 years of life, but are documented from perinatal period up to adulthood [1,3,4,5]. Interval time between head injury and diagnosis of GSF varies from 1 day to more than 1 year [4,6]. Clinical presentation includes seizures, focal neurological deficit and loss of consciousness [3,4,5]. Characteristic pathophysiological features of GSFs are defined as (1) linear skull fracture, gaping more than 4 mm, (2) Fig. 1 Cerebral MRI scan at the age of 10 months (7 months after initial right-sided linear skull fracture) showing cystic encephalomalacia with leptomeningeal cyst and herniation of brain tissue into the fracture site with occipital ventricular dilatation Eur J Pediatr (2003) 162: 556–557 DOI 10.1007/s00431-003-1256-1