Surgical treatment of depressed fracture of skull in neonates

doi:10.3969/j.issn.1672-6731.2024.10.008

Abstract

Abstract:

Objective: To explore the surgical treatment of depressed fracture of skull in neonates. Methods and Results: Eight neonates with depressed fracture of skull who underwent surgery in Children's Hospital Affiliated to Shandong University from January 2021 to December 2023 were included, and all of them underwent CT thin-slice scan + 3D reconstruction of skull before surgery. According to the location, extent and depth of the depression, the depressed edge was drilled and the depressed skull was reduced by bone pry (3 cases). The depressed skull collapsed again after the bone was pried up, the skin incision was extended to reveal the depressed area, and the shaped absorbable connector was fixed in the depressed area after prying up (2 cases). Blunt separation of the skull and dura mater at the lateral corner of the anterior fontanelle, and deep bone pry to pry up the depressed skull for reduction (one case). The skull and dura mater were bluntly separated from the coronal suture at the edge of the depression, and the depressed skull was pried up and reduced by deep bone pry (2 cases). On the first day after surgery, the reexamination of CT thin-slice scan + 3D reconstruction of skull showed that the depression reduction was satisfactory. Spontaneous fracture healing was happened in one case with linear fractures; hemorrhage resorption spontaneously was happened in one case with epidural hematoma. The average follow-up was 6.80 months, and the re-examination of CT thin-slice scan + 3D reconstruction of skull showed that the skull development was normal and there was no re-depression. Conclusions: Immediate reduction of depressed fracture of skull can be achieved with surgery, and for fractures close to the anterior fontanelle or suture, the depression can be prying up through the lateral angle of the anterior fontanelle or the unclosed suture, which is more minimally invasive.

Key words: Skull fractures, Infant, newborn, Neurosurgical procedures

摘要：

目的: 探讨新生儿颅骨凹陷骨折的手术方式。方法与结果: 纳入2021年1月至2023年12月在山东大学附属儿童医院进行手术治疗的8例新生儿颅骨凹陷骨折患儿，术前均行头部CT薄层扫描+颅骨三维重建，根据凹陷部位、范围和深度，分别予以凹陷边缘钻孔，骨撬撬起凹陷颅骨复位（3例）；骨撬撬起后凹陷颅骨再次塌陷，延长切口显露全部凹陷区域，将塑形后的可吸收连接片固定于撬起后复位的凹陷区域（2例）；前囟外侧角处钝性分离颅骨和硬脑膜，深入骨撬撬起凹陷颅骨复位（1例）；凹陷边缘冠状缝处钝性分离颅骨和硬脑膜，深入骨撬撬起凹陷颅骨复位（2例）。术后第1天复查头部CT均显示凹陷复位良好。1例合并凹陷区域外线性骨折患儿骨折自然愈合，1例合并硬膜外出血患儿血肿自行吸收。平均随访6.80个月，复查头部CT均显示颅骨发育正常，无再次颅骨凹陷。结论: 手术治疗可以即刻复位颅骨凹陷骨折，对于邻近前囟或骨缝的骨折，可以通过前囟外侧角或未闭合的骨缝撬起凹陷，这一术式更为微创。

关键词: 颅骨骨折, 婴儿，新生, 神经外科手术

Bo LIU, Shi-gang XIE, Xi-zan YUE, Guang-yu WANG. Surgical treatment of depressed fracture of skull in neonates[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(10): 821-826.

刘渤, 谢仕刚, 岳喜赞, 王广宇. 新生儿颅骨凹陷骨折手术治疗[J]. 中国现代神经疾病杂志, 2024, 24(10): 821-826.

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URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2024.10.008

https://journal11.magtechjournal.com/cjcnn/EN/Y2024/V24/I10/821

Figures/Tables 4

Table 1. Clinical data of 8 neonates with depressed fracture of skull

序号	性别	就诊年龄（d）	凹陷原因	凹陷部位	凹陷范围（cm）	凹陷深度（cm）	脑出血	骨质断裂	手术方式	术后转归	随访转归
1	女性	1	产伤	左侧顶部	5.00 × 4.50 × 0.70	0.70	无	无	前囟外侧角处游离颅骨边缘，深入骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
2	男性	16	跌落伤	右侧顶部	6.00 × 4.00 × 0.80	0.80	少量	无	骨撬撬起后凹陷颅骨再次塌陷，延长切口显露全部凹陷区域，将塑形后的可吸收连接片固定于撬起后复位的凹陷区域	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
3	男性	1	产伤	左侧额部	5.00 × 4.00 × 0.80	0.80	无	无	凹陷边缘冠状缝处钝性分离颅骨和硬脑膜，深入骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
4	男性	14	产伤	左侧顶部	4.00 × 4.00 × 0.60	0.60	无	无	骨撬撬起后凹陷颅骨再次塌陷，延长切口显露全部凹陷区域，将塑形后的可吸收连接片固定于撬起后复位的凹陷区域	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
5	女性	3	产伤	左侧额部	4.00 × 3.00 × 0.90	0.90	无	无	凹陷边缘冠状缝处钝性分离颅骨和硬脑膜，深入骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
6	男性	3	产伤	右侧顶部	4.50 × 3.00 × 0.70	0.70	无	无	凹陷边缘钻孔，骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
7	男性	2	产伤	右侧顶部	6.00 × 5.00 × 1.00	1.00	无	顶骨	凹陷边缘钻孔，骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
8	男性	11	产伤	右侧顶部	4.00 × 4.00 × 0.60	0.60	无	无	凹陷边缘钻孔，骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷

Table 1. Clinical data of 8 neonates with depressed fracture of skull

序号	性别	就诊年龄（d）	凹陷原因	凹陷部位	凹陷范围（cm）	凹陷深度（cm）	脑出血	骨质断裂	手术方式	术后转归	随访转归
1	女性	1	产伤	左侧顶部	5.00 × 4.50 × 0.70	0.70	无	无	前囟外侧角处游离颅骨边缘，深入骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
2	男性	16	跌落伤	右侧顶部	6.00 × 4.00 × 0.80	0.80	少量	无	骨撬撬起后凹陷颅骨再次塌陷，延长切口显露全部凹陷区域，将塑形后的可吸收连接片固定于撬起后复位的凹陷区域	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
3	男性	1	产伤	左侧额部	5.00 × 4.00 × 0.80	0.80	无	无	凹陷边缘冠状缝处钝性分离颅骨和硬脑膜，深入骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
4	男性	14	产伤	左侧顶部	4.00 × 4.00 × 0.60	0.60	无	无	骨撬撬起后凹陷颅骨再次塌陷，延长切口显露全部凹陷区域，将塑形后的可吸收连接片固定于撬起后复位的凹陷区域	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
5	女性	3	产伤	左侧额部	4.00 × 3.00 × 0.90	0.90	无	无	凹陷边缘冠状缝处钝性分离颅骨和硬脑膜，深入骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
6	男性	3	产伤	右侧顶部	4.50 × 3.00 × 0.70	0.70	无	无	凹陷边缘钻孔，骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
7	男性	2	产伤	右侧顶部	6.00 × 5.00 × 1.00	1.00	无	顶骨	凹陷边缘钻孔，骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷
8	男性	11	产伤	右侧顶部	4.00 × 4.00 × 0.60	0.60	无	无	凹陷边缘钻孔，骨撬撬起凹陷颅骨复位	凹陷骨折复位良好，无新发脑出血	头部外观正常，颅骨发育正常，无再次颅骨凹陷

Figure 1 Case 8 patient was admitted to hospital for 11 d due to the depressed fracture of the right parietal lobe, and was clinically diagnosed with a depressed fracture of the right parietal lobe of skull, and underwent depression fracture of skull reduction surgery (drilling of the edge of the depression, and the reduction of the depressed fracture by bone prying). Head CT thin-slice scan + 3D reconstruction of skull findings before and after surgery Preoperative axial CT bone window (Panel 1a) + 3D reconstruction of skull (Panel 1b) showed that the right parietal bone was bony depression with a range of 4.00 cm × 4.00 cm × 0.60 cm, and a depth of 0.60 cm. On the first day after surgery, axial CT bone window (Panel 1c) + 3D reconstruction of skull (Panel 1d) showed the depressed fracture was well reduced. Follow-up 3 months after surgery, axial CT bone window (Panel 1e) + 3D reconstruction of skull (Panel 1f) showed the skull was developed normally and there was no re-depression.

Figure 2 Case 4 patient was admitted to hospital for 14 d due to the depressed fracture of the left parietal lobe, and was clinically diagnosed with a depressed fracture of the left parietal lobe of the skull, and underwent depressed fracture of skull reduction surgery (the depressed skull collapsed again after the bone pry was pried, the skin incision was extended to expose the entire depressed fracture area, and the shaped absorbable connection piece was fixed in the depressed fracture area that was reduced after prying). Head CT thin-slice scan + 3D reconstruction of skull findings before and after surgery Preoperative axial CT bone window (Panel 2a) + 3D reconstruction of skull (Panel 2b) showed the left parietal bone was depressed in the range of 4.00 cm × 4.00 cm × 0.60 cm, and the depth of 0.60 cm. On the first day after surgery, axial CT bone window (Panel 2c) + 3D reconstruction of skull (Panel 2d) showed the depressed fracture was well reduced. Follow-up 4 months after surgery, axial CT bone window (Panel 2e) + 3D reconstruction of skull (Panel 2f) showed the skull was developed normally and there was no re-depression.

Figure 3 Case 5 patient was admitted to hospital for 3 d due to the depressed fracture of the left frontal lobe, and was clinically diagnosed with a depressed fracture of the left frontal lobe of the skull, and underwent depressed fracture of skull reduction surgery (blunt separation of the skull and dura mater at the coronal suture at the edge of the depression, and deep bone pry to pry the depressed fracture for reduction). Head CT thin-slice scan + 3D reconstruction of skull findings before and after surgery Preoperative axial CT bone window (Panel 3a) + 3D reconstruction of skull (Panel 3b) showed the left frontal bone was depressed with a range of 4.00 cm × 3.00 cm × 0.90 cm, and a depth of 0.90 cm. On the first day after surgery, axial CT bone window (Panel 3c) + 3D reconstruction of skull (Panel 3d) showed the depressed fracture was well reduced. Follow-up 5 months after surgery, axial CT bone window (Panel 3e) + 3D reconstruction of skull (Panel 3f) showed the skull was developed normally and there was no re-depression.

References 22

1	Amin AA , Al-Zeky AM , El-Azm M . Vacuum extraction as a treatment modality of neonatal skull depression in a twin infant. Saudi Med J, 2007, 28: 1122- 1124.
2	Yu L , Yu T , Hu JG . Non-surgical therapy on skull simple depressed fractures in neonate. Zhonghua Xiao Er Wai Ke Za Zhi, 2012, 33: 881- 885. doi: 10.3760/cma.j.issn.0253-3006.2012.12.001
	余雷, 余腾, 胡家高. 新生儿单纯颅骨凹陷骨折的非手术治疗. 中华小儿外科杂志, 2012, 33: 881- 885. doi: 10.3760/cma.j.issn.0253-3006.2012.12.001
3	Rehm A , Promod P , Ogilvy-Stuart A . Neonatal birth fractures: a retrospective tertiary maternity hospital review. J Obstet Gynaecol, 2020, 40: 485- 490. doi: 10.1080/01443615.2019.1631770
4	Wang HW , Lu LH , Zhu XP . An analysis of 22 cases with neonatal skull fracture. Jiangsu Yi Yao, 2021, 47: 234- 237.
	王华伟, 陆良华, 朱雪萍. 新生儿颅骨骨折22例分析. 江苏医药, 2021, 47: 234- 237.
5	Tayeh C , Bali B , Milad N , Najjar M . Congenital depression of the skull in a neonate. BMJ Case Rep, 2016, bcr2016215437. doi: 10.1136/bcr-2016-215437
6	Zalatimo O , Ranasinghe M , Dias M , Iantosca M . Treatment of depressed skull fractures in neonates using percutaneous microscrew elevation. J Neurosurg Pediatr, 2012, 9: 676- 679. doi: 10.3171/2012.2.PEDS11304
7	Xue XD . Pediatrics. 2nd ed Beijing: People's Medical Publishing House, 2010: 5.
	薛辛东. 儿科学. 2版北京: 人民卫生出版社, 2010: 5.
8	Zhang JZ . Pediatric trauma surgery. Hangzhou: Zhejiang Science and Technology Publishing House, 2006: 66.
	张金哲. 小儿创伤外科学. 杭州: 浙江科学技术出版社, 2006: 66.
9	El Damaty A , Jurgowski D , Unterberg A . Closed reduction of ping-pong fracture in a neonate. World Neurosurg, 2020, 139: 377. doi: 10.1016/j.wneu.2020.04.111
10	Shao X , Qin R , Sun MT . A case of depressed skull fracture in the neonate. Zhongguo Yi Yao Ke Xue, 2024, 14: 185- 187.
	邵珣, 秦蓉, 孙梦婷. 新生儿颅骨凹陷性骨折1例. 中国医药科学, 2024, 14: 185- 187.
11	Neto CDRL , Coelho G , Figueiredo EG . A new device to treat ping-pong skull fractures: the hammer puller technique. A comparative analysis using a realistic simulation model. Surg Neurol Int, 2024, 15: 180. doi: 10.25259/SNI_141_2024
12	Martinez EL , Welscher A , Shah MN , Sandberg DI . Elevation of depressed skull fracture in neonates using a breast pump and a custom-molded flange. Oper Neurosurg (Hagerstown), 2024, 27: 114- 119.
13	Agrawal SK . the skull in neonate: a case of successful conservative management. J Child Neurol, 2010, 25: 387- 389. doi: 10.1177/0883073809338520
14	Mastrapa TL , Fernandez LA , Alvarez MD , Storrs BB , Flores-Urueta A . Depressed skull fracture in Ping Pong: elevation with Medeva extractor. Childs Nerv Syst, 2007, 23: 787- 790. doi: 10.1007/s00381-007-0354-1
15	Shi W , Xue P , Zhao R , Li H . Experience in the treatment of skull depression fracture in neonates. Zhonghua Shen Jing Wai Ke Za Zhi, 2020, 36: 570- 573. doi: 10.3760/cma.j.cn112050-20190124-00021
	施伟, 薛萍, 赵瑞, 李昊. 新生儿颅骨凹陷性骨折的治疗体会. 中华神经外科杂志, 2020, 36: 570- 573. doi: 10.3760/cma.j.cn112050-20190124-00021
16	Preston D , Jackson S , Gandhi S . Non-traumatic depressed skull fracture in a neonate or 'ping pong' fracture. BMJ Case Rep, 2015, bcr2014207077. doi: 10.1136/bcr-2014-207077
17	Hung KL , Liao HT , Huang JS . Rational management of simple depressed skull fractures in infants. J Neurosurg, 2005, 103 (1 Suppl): 69- 72.
18	Flannigan C , O'Neill C . Faulty fetal packing. BMJ Case Rep, 2011, bcr0220113802.
19	Gui LL , Lu W , Xing FZ , Xiao BD , Xiong XF , Yu L . Role of negative pressure suction for depressed skull fractures in neonates. Zhonghua Xiao Er Wai Ke Za Zhi, 2019, 40: 893- 898. doi: 10.3760/cma.j.issn.0253-3006.2019.10.006
	桂琳玲, 鲁巍, 邢福中, 肖必栋, 熊晓峰, 余雷. 新生儿颅骨凹陷性骨折负压抽吸术治疗方法的研究. 中华小儿外科杂志, 2019, 40: 893- 898. doi: 10.3760/cma.j.issn.0253-3006.2019.10.006
20	Li J , Song K , Li RZ , Ye QS , Kou JJ . Fetal head aspirator in restoration of neonatal large area depressed skull fracture: report of one case and literature review. Lin Chuang Shen Jing Wai Ke Za Zhi, 2024, 21: 477- 480. doi: 10.3969/j.issn.1672-7770.2024.04.024
	李杰, 宋凯, 李汝珍, 叶庆寿, 寇军军. 胎头吸引器复位新生儿颅骨大面积凹陷性骨折1例并文献复习. 临床神经外科杂志, 2024, 21: 477- 480. doi: 10.3969/j.issn.1672-7770.2024.04.024
21	Johnston JM , Park TS . Depressed skull fracture. J Neurosurg, 2006, 105 (6 Suppl): 515- 516.
22	Sun N , Zhang QJ , Zhan JH , Ma X , Wei ZN . Clinical explorations of skull depression in neonates. Lin Chuang Xiao Er Wai Ke Za Zhi, 2017, 16: 496- 498. doi: 10.3969/j.issn.1671-6353.2017.05.018
	孙宁, 张庆江, 詹江华, 马骁, 魏中南. 新生儿颅骨凹陷骨折治疗方法的探讨. 临床小儿外科杂志, 2017, 16: 496- 498. doi: 10.3969/j.issn.1671-6353.2017.05.018

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