Congenital depression of the fetal skull

Decision-making challenge of Ping-Pong Fractures in children: systematic review of literature

Ping-pong fractures (PPF) have become less frequent and no definite predictors to determine which fractures will elevate spontaneously and which should undergo surgical treatment have not been clearly defined. Herein, the authors present a revision of the literature, in which 54 papers were included, with a total of 228 children studied. Patients who underwent surgery accounted for 30%; elevation through obstetrical vacuum or other aspiration systems was applied in 30%, spontaneous resolution occurred in 40%; in 4 patients percutaneous microscrew elevation was applied. Overall, in 96.4% of patients the outcome was favorable since we found no significant increase in the incidence of post-traumatic seizures or neurologic sequelae with no significant differences between treated patients and spontaneous elevation. Statistical analysis showed no significant differences among the different treatment methods (P=0.53). Our results suggest that simple compound PPFs without brain compression, hematomas or dural tears could benefit from conservative management. In cases of non-spontaneous resolution after 6 months, operative strategies should be performed, considering that there is no evidence of differences between vacuum elevation and surgical elevation.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Congenital skull indentation: a case report and review of the literature

Congenital depressions of the skull are rare in Western countries. The majority relate to obstetric trauma at delivery. We present a case of a congenital depression of a neonate's skull not relating to obstetric trauma. The child had an ovoid indentation behind the right coronal suture in the temperoparietal region. This skull depression was thought to relate to the position of her right hand in utero. We report her management, neuro-imaging and outcome on follow-up. A literature review is given in brief.

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.