Ping-pong Fracture Research Articles

Depressed "ping pong" skull fractures in the newborns: A cohort study.

A ping pong fracture is a rare depressed skull fracture (DSF) observed in infants. It occurs due to the inward buckling of the calvarium, creating a cup-like shape. Trauma during childbirth, particularly from instrumental delivery or the application of pressure by physicians or midwives during challenging deliveries, is the primary cause. This study aimed to investigate the epidemiologic characteristics associated with DSF in newborns and to identify the main factors related to its incidence and the type of hematoma involved. This is a retrospective case-control analysis of all newborns delivered with DSF at King Abdulla University Hospital in Jordan between January 2008 and December 2020. The medical records were reviewed, and clinical data were collected and analyzed. Out of 42,955 live births delivered at King Abdulla University Hospital, 13 cases of DSF were observed, giving an incidence of 3.0 in 10,000 live births. All cases were delivered at full term. Of the 13 cases, nine cases were associated with the use of instrumental delivery. Seven of those nine cases were delivered vaginally, while the other two cases required cesarean section following unsuccessful instrumental delivery. Four cases were spontaneous, with no history of trauma or instrument use, and delivered by cesarean section. Only 3 of the 13 cases required neurosurgical elevation of DSF. The outcome was excellent in all cases, both cosmetically and neurologically. Ping-pong skull fractures are seen in newborns infrequently in the Jordanian population, with an incidence of 0.03%. Most of the cases have resulted from difficult deliveries though spontaneous fractures can be encountered rarely. The treatment is usually conservative with spontaneous resolution. The overall prognosis is excellent both neurologically and cosmically.

Pediatric ping-pong skull fractures treated with vacuum-assisted elevation.

Depressed ("ping-pong") skull fractures can be treated by different means, including observation, non-surgical treatments, or surgical intervention. The authors describe their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate variables associated with surgical outcomes. The authors present a retrospective review of all ping-pong skull fractures treated with vacuum-assisted elevation at the Children's Hospital of Orange County in 2021-2022. Variables included patient age, mechanism of injury, fracture depth, bone thickness at the fracture site, and degree of elevation. Seven patients underwent vacuum-assisted elevation of ping-pong fractures at thebedside without the use of anesthesia. Fractures caused by birth-related trauma were deeper than those caused by falls (p < 0.001). There was no significantdifference between groups in bone thickness at the fracture site (2.10mm vs 2.16mm, n.s). Six of the seven patients experienced significant improvement in fracture site depression, with four displaying a complete fracture reduction and two displaying a significant reduction. The degree of fracture reduction was modestly related to the depth of fracture, with the two deepest fractures failing to achieve full reduction. Age appeared to be related to fracture reduction, with the lowest reduction observed in one of the oldest patients in this sample. No complications were observed in any patient other than temporary mild swelling at the suction site, and no re-treatment or surgery for the fractures was required. Vacuum-assisted elevation of ping-pong skull fractures is a safe and effective noninvasive treatment option for infants that can be used under certain circumstances. The procedure can be done safelyat the bedsideand is a relatively quick procedure.Itavoids the need for open surgical intervention, anesthesia, or hospital admission, andcan lead to excellent outcomes.

Elevation of Depressed Skull Fracture in Neonates Using a Breast Pump and a Custom-Molded Flange.

"Ping-pong fractures" (PPF) can occur in neonates and result in cosmetic deformity and local mass effect. Standard treatment involves surgical elevation of the depressed bone when the indentation is considerable or cosmetically apparent. Surgical correction of PPF subjects patients to the risks of surgery and general anesthesia. This article and corresponding video demonstrate a novel means of correcting PPF at bedside without surgery or anesthesia. We used a hospital-grade breast pump connected to a custom-fabricated flange to successfully elevate PPF in two neonates. Two moderately preterm infants were noted at birth to have large parietal PPF. To avoid surgical intervention, elevation using a suction device was attempted. A hospital-grade breast pump was used to provide suction. A custom device was fabricated out of a breast pump flange and molded Coloplast Brava® protective seal rings. This device was carefully applied to the skull to exactly match the diameter of the PPF and contour of the bone. Brief (15-30 seconds) periods of suction were applied several times until the PPF was successfully elevated as documented on subsequent computed tomography scans. Both infants achieved excellent cosmetic results with no adverse effects over 24- and 9-month follow-ups, respectively. This technique eliminates the risks of open surgical correction and corrected the PPF without general anesthesia or adverse effects to the infant. While there may be limitations due to patient age and/or location of the PPF, the use of widely available and inexpensive custom-fitted materials with a hospital grade breast pump achieves maximal efficacy without requiring higher negative pressure suction application. Elevation of PPF can be safely achieved in some neonates using readily available equipment: a hospital-grade breast pump, flange, and moldable adherent material. This technique is reasonable to attempt in lieu of surgical elevation.

A new device to treat ping-pong skull fractures: The hammer puller technique. A comparative analysis using a realistic simulation model.

This study aims to describe a new surgical technique for the treatment of ping-pong skull fractures and to evaluate its efficacy in a realistic simulation model compared to the dissector elevation technique. A total of 64 fractures were obtained using 16 model units, each with four fractures (two frontal and two parietal). The hammer puller technique was applied for left-sided fractures and the dissector technique for right-sided fractures. The variables evaluated were fracture repair time, fracture volume, fracture corrected volume, and fracture correction percentage. Fractures were separated into groups according to the surgical technique used (hammer or dissector) and the bone fractured (frontal or parietal). Statistical analysis was performed with Jamovi® software (version 2.3) using Student's t-test. A complete degree of fracture correction was achieved with both techniques, demonstrating a sufficient performance in the correction of the deformity. The hammer technique was shown to be faster in correcting frontal bone depressions with 20.1 ± 7.8 s compared to 31.3 ± 4.7 s for the dissector technique, P < 0.001. There was no statistically significant difference for parietal applications (P = 0.405). This study describes a new minimally invasive surgical technique for the treatment of ping-pong fractures. Comparative analysis showed that both techniques were equally effective but that the hammer puller technique was more efficient than the dissector elevation technique, especially for frontal bone fractures.

Treatment of depressed skull fractures with vacuum devices in the neonatal period: A case series.

The management of depressed skull fractures in infants can be either conservative or surgical. This study aimed to examine the outcomes of management with a negative-pressure vacuum device on depressed skull fractures in newborns. Twenty-eight patients (aged 1-6days) with simple depressed skull fractures underwent skull elevation using negative-pressure vacuum devices. A protocol for nonsurgical management was adopted for infants with such fractures between 2010 and 2023. All patients were initially evaluated with neurological examination and complementary assessments-hematological and coagulation studies, transfontanel transcranial ultrasound, skull radiography, and computed tomography scanning with three-dimensional reconstruction-according to availability and clinical needs. Gentle (negative) extraction pressure was applied with one of several devices (according to institutional availability) for a maximum duration of 60s; this was performed as soon as possible after diagnosis, preferably within 72h. Follow-up data, available in the clinical records, were reported. All patients exhibited satisfactory elevation of the depressed bone without associated injuries, except one patient who presented with an associated cephalohematoma which prevented optimal device coupling to generate sufficient vacuum pressure for correction. Neither neurological deficits nor development of epilepsy was noted; normal neurological assessment and oral alimentation tolerance were confirmed within 24h post procedure. According to our data, ping-pong skull fracture elevation using the vacuum method is a safe and satisfactory treatment in the neonatal period. Early treatment allows for quick resolution, and in our opinion is the strategy of choice for depressed skull fractures in newborns.

Spontaneous ping-pong fracture in a full-term neonate—a case report

BackgroundNon-traumatic depressed skull fracture in a neonate delivered by cesarean section is a rare phenomenon. The incidence reported in literature varies between 1 and 2.5 in every 10,000 live births. The skull is transformed from its normal convex shape to a more concave form due to easy malleability. This is secondary to the lack of complete ossification in the neonatal period. Hence, it is commonly known as ping-pong fracture. The clinical presentation may vary depending on the severity of the fracture and underlying parenchymal injury. Most cases reported in literature have been managed conservatively. However, surgical elevation and the use of medical devices may be advised in severe cases.Case presentationWe report the presentation, course, and management of a term female neonate with a spontaneous ping-pong fracture. The neonate had no history suggestive of antenatal insult, difficult labor, or trauma due to instrumentation during delivery. The infant was thoroughly investigated for underlying parenchymal injury, observed for neurological abnormality, and managed conservatively.ConclusionThus, ping-pong fractures or spontaneous neonatal skull fractures are rare but can be encountered in clinical practice. A thorough clinical examination and neurological assessment can aid management decisions.

CT-like MR-derived Images for the Assessment of Craniosynostosis and other Pathologies of the Pediatric Skull

PurposeTo evaluate the diagnostic value of CT-like images based on a 3D T1-weighted spoiled gradient echo-based sequence (T1SGRE) for the visualization of the pediatric skull and the identification of pathologies, such as craniosynostosis or fractures.MethodsIn this prospective study, 20 patients with suspected craniosynostosis (mean age 1.26 ± 1.38 years, 10 females) underwent MR imaging including the T1SGRE sequence and 2 more patients were included who presented with skull fractures (0.5 and 6.3 years, both male). Additionally, the skull of all patients was assessed using radiography or CT in combination with ultrasound. Two radiologists, blinded to the clinical information, evaluated the CT-like images. The results were compared to the diagnosis derived from the other imaging modalities and intraoperative findings. Intrarater and interrater agreement was calculated using Cohen’s κ.ResultsOf the 22 patients 8 had a metopic, 4 a coronal and 2 a sagittal craniosynostosis and 2 patients showed a complex combination of craniosynostoses. The agreement between the diagnosis based on the T1SGRE and the final diagnosis was substantial (Cohen’s κ = 0.92, 95% confidence interval (CI) 0.77–1.00 for radiologist 1 and κ = 0.76, CI 0.51–1.00 for radiologist 2). Of the patients with fractures, one presented with a ping pong fracture and one with a fracture of the temporal bone. Both radiologists could identify the fractures using the T1SGRE.ConclusionThe visualization of the pediatric skull and the assessment of sutures using a CT-like T1SGRE MR-sequence is feasible and comparable to other imaging modalities, and thus may help to reduce radiation exposure in pediatric patients. The technique may also be a promising imaging tool for other pathologies, such as fractures.

Elevation of depressed (pond) fracture in infant using a vacuum-assisted device: Technical note

Abstract Introduction: Pond fracture also called ping-pong fracture in children is caused due to direct impact on the skull. It is rare and many types of treatment modalities have been described. In this report, we describe a makeshift vacuum-assisted device to elevate the fracture, which is both cost-effective and efficient. Case presentation: A 5-month-old infant was brought to the emergency department with a history of fall of heavy object on the head resulting in pond fracture over the left parietal area and an episode of focal motor seizures. After ruling out an intracranial injury with a computer tomogram, we elevated the depressed fracture by a makeshift vacuum suction device using a plastic funnel connected to vacuum chamber. Post-procedure child had one episode of focal seizure and was discharged after a brief period of observation. Conclusion: Plastic funnel vacuum suction can be effectively used to elevate the Pond fractures in infants with appropriate precautions.

A new, readily accessed and low-cost, device for treating depressed ping pong fractures non-surgically: Technical note

ObjectiveThe aim of this paper is to describe a low-cost and readily accessed Manual Aspiration Reduction System (MARS) for use treating ping-pong fractures in three patients. MethodsThe MARS is composed of a pediatric anesthesia mask, part of a macro dripper, a 3-way stopcock, and two 60-ml syringes. Prior to its use in our patient, the system was tested on five adult volunteers to maximum negative pressure, and none reported pain during the procedure or experienced any other complication.We present three clinical cases of patients with depressed ping-pong fracture who were treated with the MARS at the bedside without anesthesia. The patients were monitored by the neonatology team throughout the procedure. ResultsSkull radiography revealed reduction of the fracture after the procedure performed with the MARS in all patients. The transfontanellar ultrasound and follow-up neurological examination were normal. The patient progressed favorably and was discharged from our service after 24 h. ConclusionsDue to its components, the MARS is a low-cost and readily accessed system. In this case, it permitted satisfactory reduction of a ping-pong fracture in all patients. This system should greatly simplify the treatment of such fractures.

Vacuum-assisted elevation of pediatric ping-pong skull fractures: a case series and technical note.

The management of children with ping-pong skull fractures may include observation, nonsurgical treatments, or surgical intervention depending on the age, clinical presentation, imaging findings, and cosmetic appearance of the patient. There have been 16 publications on nonsurgical treatment using negative pressure with various devices. Herein, the authors report their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate the variables affecting procedural outcomes. The authors performed a retrospective chart review of all ping-pong skull fractures treated via vacuum-assisted elevation at the Children's Hospital of Wisconsin between 2013 and 2017. Data collected included patient age, head circumference, mode of injury, time to presentation, imaging findings, procedural details, treatment outcomes, and complications. Four neonates and 5 infants underwent vacuum-assisted elevation of moderate to severe ping-pong skull fractures during the study period. Modes of injury included birth-related trauma, falls, and blunt trauma. All patients had normal neurological examination findings and no evidence of intracranial hemorrhage. All fractures were deemed severe enough to require elevation by the treating neurosurgeon. All fractures involved the parietal bone. Skull depressions ranged from 23 to 62 mm in diameter and from 4 to 14 mm in depth. Bone thickness ranged from 0.6 to 1.8 mm. The time from fracture to intervention ranged from 7 hours to 8 days. The Kiwi OmniCup vacuum delivery system was used in all cases. Negative pressures were increased sequentially to a maximum of 500 mm Hg. A greater number of sequential vacuum applications was required for patients with a skull thickness greater than 1 mm at the site of depression and for those undergoing treatment more than 72 hours from fracture onset. Successful fracture elevation was attained in 7 of 9 patients. Two patients required subsequent surgical elevation of their fractures. Postprocedure imaging studies revealed no evidence of complications. Increasing bone thickness and time from fracture onset to intervention appeared to be the greatest limiting factors to the successful elevation of moderate to severe ping-pong fractures via this vacuum-assisted approach. This procedure is a well-tolerated option that should be considered prior to performing an open repair in cases deemed to require fracture elevation. Future efforts will focus on larger-volume studies to better delineate inclusion and exclusion criteria, and volumetric analysis for better fracture-to-suction device customization.

Closed reduction of ping-pong fracture by applying negative pressure

Closed reduction of ping-pong fracture by applying negative pressure

当院で手術を行った Ping-pong fracture の 3 症例

当院で手術を行った Ping-pong fracture の 3 症例

Obstetrical Vacuum Extraction for Ping-Pong Fracture of Newborn

Obstetrical Vacuum Extraction for Ping-Pong Fracture of Newborn

Three-Dimensional Computed Tomography Skull Reconstructions as an Aid to Child Abuse Evaluations

Skull fractures can be difficult to recognize on radiographs and axial computed tomography (CT) bone windows. Missed findings may delay abuse diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse evaluations was retrospectively evaluated. Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With the use of a 1-to-3 scale, ease and accuracy of interpretation of findings between plain films, bone windows, and 3-D CT images were independently assessed by 2 radiologists. In 7 cases, skull fractures were missed on initial review of skull films and/or bone windows. Three children sustained additional abusive injury before 3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were missed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protective intervention before additional injury. An unrecognized ping-pong fracture was discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining the injury as an impact. Two 3-Ds demonstrated communication of biparietal fractures along the sagittal suture. This changed interpretation to single, rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy of interpretation scores were highest for 3-D CT. Without increasing patient radiation exposure, 3-D CT reconstructions may reveal previously unrecognized skull fractures, potentially allowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-D reconstructions on cranial CTs for children younger than 3 years.

“Spontaneous” ping-pong fracture in newborns: case report and review of the literature

“Ping-pong” fractures (PPF) are depressed skull fractures typical of newborns. PPF usually result from head injury and, rarely, may cause severe long-term neurological sequelae. The management of PPF is still controversial. The goal of this paper is to present a case of “spontaneous” ping-pong fracture and to review the pertinent literature of the last 20 years. We report on a newborn who presented with a “spontaneous” parietal depressed skull fracture at birth. Preoperative computed tomography (CT) scan confirmed the PPF and excluded brain injuries. Neurosurgical intervention was performed on day 3 with immediate lifting of the fracture; the postoperative course was uneventful.During the last 20 years, 22 cases of “spontaneous ping-pong” fractures in newborn have been reported, with different clinical pictures and management but, generally, with a good outcome.“Ping-pong” fractures can occur in uneventful pregnancies and after uncomplicated vaginal or cesarean deliveries. CT scan, with low-dose protocol for infants, is the gold standard examination to evaluate the fracture and any associated brain lesions. Treatment is selected according to fracture characteristics.

Magnetic resonance features of closed head trauma in two foals

SummaryTwo foals were admitted for neurological signs after trauma. Clinical and diagnostic investigations were performed that were suggestive of closed head trauma characterised by right parietal bone deviation (ping‐pong fracture), cerebral contusion, haematoma and cerebellar contusion. The histopathological findings were consistent with areas of abnormal signal found on magnetic resonance investigations.

Three-dimensional skull models as a problem-solving tool in suspected child abuse

The value of 3-D skull models in evaluation of young children with suspected child abuse is not known. The purpose of this study was to assess the value of 3-D skull models as a problem-solving tool in children younger than 2years. We performed a retrospective study on 73 children (ages 0-24months) seen by a child protection team (CPT) who were undergoing head CT between August 2007 and July 2009. Of the 73 children, volume-rendered 3-D models were obtained in 26 (35.6%). Three-dimensional models changed initial CT interpretation in nine instances (34.6%). Findings thought to be fractures were confirmed as normal variants in four children. Depressed fractures were correctly shown to be ping-pong fractures in two cases. In one case, an uncertain finding was confirmed as a fracture, and an additional contralateral fracture was identified in one child. A fracture seen on skull radiographs but not seen on axial CT images was identified on the 3-D model in one case. Changes in interpretation led to modification in management in five children. Use of 3-D skull models can be a problem-solving tool when there is discordance among the CT reading, subsequent radiographic investigations and clinical evaluation.

Treatment of depressed skull fractures in neonates using percutaneous microscrew elevation

Depressed skull fractures in neonates involve the inward buckling of the skull bones to resemble a cup shape or "ping-pong ball" shape. In the past, several methods have been used to treat these fractures for cosmetic effect, including the use of vacuum extraction. The aim of this study was to demonstrate the use of a novel treatment method for these skull fractures. All patients presented to Hershey Medical Center between May 2007 and March 2010. All underwent treatment of their ping-pong skull fracture using a novel technique of percutaneous screw elevation with self-tapping microscrews (4 or 5 mm) typically used in neurosurgery for cranial plating. Four patients were treated, all between the ages of 2 days and 4 months. Two of the patients were treated under general anesthesia and 2 with local anesthesia only. All patients had good cosmetic results and experienced no adverse events. Percutaneous screw elevation of the ping-pong type, simple depressed skull fracture in neonates is a feasible method of treatment with a low complication rate associated with the procedure and no risk from anesthesia.

Spontaneous Resolution of Atraumatic Intrauterine Ping-Pong Fractures in Newborns Delivered by Cesarean Section

Two cases of spontaneous intrauterine ping-pong fractures are reported in newborns delivered by cesarean section. Skull fractures occurred with no evidence of extrinsic trauma or cephalopelvic disproportion. Subsequent clinical follow-up at 6 and 12 months revealed normal skull reshaping and growth, with no associated neurological deficits. Spontaneous intrauterine ping-pong fractures in newborns delivered by cesarean section is a distinctly rare condition. These 2 cases demonstrate that, even without complicated spontaneous vaginal delivery or history of external trauma, congenital ping-pong fracture of the skull can occur. The existence of this clinical condition and its spontaneous resolution is important knowledge that can assist in the prepartum and postpartum management of children with this pathology.

Depressed Skull Fractures in Children: Treatment Using an Obstetrical Vacuum Extractor

Introduction: A depressed skull fracture is an inward buckling of the skull bones. It is referred to as a ping-pong ball fracture in neonates; in older children, some fractures take a cup shape mimicking ‘ping-pong’ ball fractures. Objective and Methods: The aim of this study was to assess the use of an obstetric vacuum extractor to elevate cup-shaped depressed skull fractures in children irrespective of age. All children admitted into the Central Hospital of Yaounde between 1999 and 2004 with a cup-shaped simple depressed skull fracture and treated with the vacuum extractor were included. Results: Nine children aged from 3 months to 17 years were treated with the vacuum extractor. The cosmetic and radiographic results were satisfactory. The procedure was simple and without any complication. Conclusion: The elevation of ‘ping-pong-ball-like’ or ‘cup-shaped’ skull fractures in older children (beyond the neonatal period) is a simple, effective and safe procedure.