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Depressed fractures of the skull in infants
Depressed
Fractures
of the Skull in Infants
Surgical Management EDWIN M. TODD, M.D. AND BENJAMIN L. CRWE, JR., M.D., Los Angeles, California
From the Departmentof Neurological Surgery, University of Southern California, Los Angeles, California.
grees of complexity and risk. Incisions are economical but adequate, plotted to allow complete exposure if necessary when preliminary segmental opening does not suffice. Proper planning permits later extension with due regard for natural forehead creases, hairline boundaries, longitudinal fiber arrangement of galea, and major vessel pathways. It is often possible to elevate the fragments with disarming ease by simply hooking the depths of the crevice and snapping it back in place through a puncture opening. Uncorking in this fashion is a worthy initial effort. A convenient device for the maneuver is illustrated in Figure 1. Subsequent management follows a pattern. Most textbooks describe the popular practice of making a small burrhole at one edge of the defect for gently insinuating a flat periosteal instrument to elevate the fragments [1,2]. The Gardner technic employing a dental drill to cut a narrow trench about the rim is preferable in that it provides a broader sweep for the instrument. (Fig. 2A.) Moreover, it sets the stage for a variety of alternate measures if necessary. Greater flexibility is evident when the infolding fragments are firmly wedged to defy the crowbar action of the instrument. A T-shaped extension of the trench, slitting the center of the depression with a small shears or dental drill, often overcomes this obstacle. (Fig. 2B.) While it is true that most of the smaller lesions will respond with facility to these simple measures, a few will stubbornly resist owing to a folding or kinking tendency peculiar to the thin membranous infantile calvarium. Refractory small lesions are managed in the fashion of the larger ones. Larger depressions are particularly amenable
HE ESSENCE of refinement in surgical techT nic is simplicity. Accordingly, efforts to
organize random methods into systems of natural progression warrant attention. It is the purpose of this paper to present a simple, efficient program of surgical management for depressed fractures of the skull in infants. Certain distinctive anatomic features of the infantile skull impart a unique character to these fractures. The bones of the neonatal calvarium exist as separate islands surrounded by uncalcified suture areas which serve to dissipate traumatic forces and limit depressions to sites of direct contact. Moreover, the greenstick nature of the bone in the prediploid structure predisposes to infolding rather than splintering, so that the indentation simulates the intact depression of a ping pong ball rather than the fragmentation of an eggshell. With the development of the two-tabled structure as ossification proceeds, shattering is liable to occur, and the problems of decompression are compounded by underriding of indriven inner table fragments. An awareness of these distinctions is essential to the proper selection of surgical procedure. Minor niching and flattening of contours will usually resolve spontaneously, but the decision to operate is automatic with any significant depression owing to the relatively explosive expansion of the brain in the first two years of life. Surgical intervention is to insure that the bone barrier provided to protect must not retard or maim. OPERATIVE
METHODS
It is naturally desirable to proceed from the ultimate in simplicity through graduated deVol. 113, April
1967
479
480
Todd and Crue
FIG. 2. Unpopping trench.
Frc. 1. Technic for uncorking fracture elevator.
fracture
with depressed
to the flip procedure (Fig. 3) in which the dental drill continues around the rim to complete the circle. (Fig. 3C.) The detached bony concavity is lifted free, smoothed with the fingers or lightly hammered to desired contour, flipped over, and replaced inside out as a normal convexity. (Fig. 3D.) The flip procedure is particularly appropriate for restoring the natural contour of the parietal or frontal prominence. Although not unique, the depression incurred from displacement of delivery forceps is fairly characteristic, and a variation of the flip procedure serves admirably for correction. The indentation usually extends longitudinally through the entire parietal bone with minor overlapping of adjacent temporal, occipital, or frontal bones. Here, instead of completely circling the rim with the dental drill, a Ushaped trench is made, hinging on the coronal suture. (Fig. 3A.) The flap is lifted, reshaped with fingers or pliers, and replaced. (Fig. 3B.) Two or three fixation sutures anchor posteriorly. The nature of the fracture begins to approximate adult forms with later development of the two-tabled skull structure. Each table fragments independently but still less completely because of the persistent plasticity of poorly calcified bone. Tightly wedged and kinked fragments are delicately isolated and freed from underriding positions by skillful application of the dental drill, a distinct refinement over crude biting with rongeurs.
by lever action through slit or “T”
In this manner the fragments are best preserved for mosaic patching of the defect. (Fig. 4.) The immediate mosaic cranioplasty can be accomplished successfuIly in simple fractures in which the dura is torn and in the presence of contaminated compound fractures in which the dura is intact, but this is always a matter for individual decision. All fragments are normally removed in compound fractures when the dura is perforated. It may be argued
FLIP
FIG. 3. Hinge and flip procedures. American
Journal
of Surgery
Fractures
of Skull SUMMARYANDCONCLUSION
..
’
MOSAIC FIG. 4. Primary
mosaic
cranioplasty.
that all fragments must be removed in compound fractures to minimize the potential for infection. Moreover, cranioplasty is relatively simple to perform at a later date. However, the reality of practical experience has demonstrated to us that these fragments can be fitted into a mosaic repair in most cases and we have rarely had to reopen.
Vol.113, April 1967
The fruits of experience are a multiple selection of alternative procedures to fit any circumstance. ;Llaturation and sophistication of technical skill are reflected in the manner of choice. In the interests of economy and simplicity an assortment of accepted methods for dealing with depressed fractures in infants are arranged in a graduated order to minimize surgical effort in any given situation. Acknowledgment: We gratefully acknowledge the assistance of Mr. Zolton k’uhasz, medical illustrator, of Mr. Trent Wells of Mechanical Developments Company, in making the depressed fracture elevator, and of the neurosurgical residents at Los Angeles County (ienera1 Hospital in the management of patients. REFERENCES 1. GORDY. I'.D. Pediatric h’eurosurgery. p. X4. Edited by Jackson, I. J. and Thompson, R. K. Springfield, Ill., 1959. Charles C Thomas. 2. INGRAHAM, F. D. and MATSON, D. D. Seurosurgery of Infancy and Childhood, p. 450. Springfield, Ill., 1954. Charles C Thomas.
Fractures
of the Skull in Infants
Surgical Management EDWIN M. TODD, M.D. AND BENJAMIN L. CRWE, JR., M.D., Los Angeles, California
From the Departmentof Neurological Surgery, University of Southern California, Los Angeles, California.
grees of complexity and risk. Incisions are economical but adequate, plotted to allow complete exposure if necessary when preliminary segmental opening does not suffice. Proper planning permits later extension with due regard for natural forehead creases, hairline boundaries, longitudinal fiber arrangement of galea, and major vessel pathways. It is often possible to elevate the fragments with disarming ease by simply hooking the depths of the crevice and snapping it back in place through a puncture opening. Uncorking in this fashion is a worthy initial effort. A convenient device for the maneuver is illustrated in Figure 1. Subsequent management follows a pattern. Most textbooks describe the popular practice of making a small burrhole at one edge of the defect for gently insinuating a flat periosteal instrument to elevate the fragments [1,2]. The Gardner technic employing a dental drill to cut a narrow trench about the rim is preferable in that it provides a broader sweep for the instrument. (Fig. 2A.) Moreover, it sets the stage for a variety of alternate measures if necessary. Greater flexibility is evident when the infolding fragments are firmly wedged to defy the crowbar action of the instrument. A T-shaped extension of the trench, slitting the center of the depression with a small shears or dental drill, often overcomes this obstacle. (Fig. 2B.) While it is true that most of the smaller lesions will respond with facility to these simple measures, a few will stubbornly resist owing to a folding or kinking tendency peculiar to the thin membranous infantile calvarium. Refractory small lesions are managed in the fashion of the larger ones. Larger depressions are particularly amenable
HE ESSENCE of refinement in surgical techT nic is simplicity. Accordingly, efforts to
organize random methods into systems of natural progression warrant attention. It is the purpose of this paper to present a simple, efficient program of surgical management for depressed fractures of the skull in infants. Certain distinctive anatomic features of the infantile skull impart a unique character to these fractures. The bones of the neonatal calvarium exist as separate islands surrounded by uncalcified suture areas which serve to dissipate traumatic forces and limit depressions to sites of direct contact. Moreover, the greenstick nature of the bone in the prediploid structure predisposes to infolding rather than splintering, so that the indentation simulates the intact depression of a ping pong ball rather than the fragmentation of an eggshell. With the development of the two-tabled structure as ossification proceeds, shattering is liable to occur, and the problems of decompression are compounded by underriding of indriven inner table fragments. An awareness of these distinctions is essential to the proper selection of surgical procedure. Minor niching and flattening of contours will usually resolve spontaneously, but the decision to operate is automatic with any significant depression owing to the relatively explosive expansion of the brain in the first two years of life. Surgical intervention is to insure that the bone barrier provided to protect must not retard or maim. OPERATIVE
METHODS
It is naturally desirable to proceed from the ultimate in simplicity through graduated deVol. 113, April
1967
479
480
Todd and Crue
FIG. 2. Unpopping trench.
Frc. 1. Technic for uncorking fracture elevator.
fracture
with depressed
to the flip procedure (Fig. 3) in which the dental drill continues around the rim to complete the circle. (Fig. 3C.) The detached bony concavity is lifted free, smoothed with the fingers or lightly hammered to desired contour, flipped over, and replaced inside out as a normal convexity. (Fig. 3D.) The flip procedure is particularly appropriate for restoring the natural contour of the parietal or frontal prominence. Although not unique, the depression incurred from displacement of delivery forceps is fairly characteristic, and a variation of the flip procedure serves admirably for correction. The indentation usually extends longitudinally through the entire parietal bone with minor overlapping of adjacent temporal, occipital, or frontal bones. Here, instead of completely circling the rim with the dental drill, a Ushaped trench is made, hinging on the coronal suture. (Fig. 3A.) The flap is lifted, reshaped with fingers or pliers, and replaced. (Fig. 3B.) Two or three fixation sutures anchor posteriorly. The nature of the fracture begins to approximate adult forms with later development of the two-tabled skull structure. Each table fragments independently but still less completely because of the persistent plasticity of poorly calcified bone. Tightly wedged and kinked fragments are delicately isolated and freed from underriding positions by skillful application of the dental drill, a distinct refinement over crude biting with rongeurs.
by lever action through slit or “T”
In this manner the fragments are best preserved for mosaic patching of the defect. (Fig. 4.) The immediate mosaic cranioplasty can be accomplished successfuIly in simple fractures in which the dura is torn and in the presence of contaminated compound fractures in which the dura is intact, but this is always a matter for individual decision. All fragments are normally removed in compound fractures when the dura is perforated. It may be argued
FLIP
FIG. 3. Hinge and flip procedures. American
Journal
of Surgery
Fractures
of Skull SUMMARYANDCONCLUSION
..
’
MOSAIC FIG. 4. Primary
mosaic
cranioplasty.
that all fragments must be removed in compound fractures to minimize the potential for infection. Moreover, cranioplasty is relatively simple to perform at a later date. However, the reality of practical experience has demonstrated to us that these fragments can be fitted into a mosaic repair in most cases and we have rarely had to reopen.
Vol.113, April 1967
The fruits of experience are a multiple selection of alternative procedures to fit any circumstance. ;Llaturation and sophistication of technical skill are reflected in the manner of choice. In the interests of economy and simplicity an assortment of accepted methods for dealing with depressed fractures in infants are arranged in a graduated order to minimize surgical effort in any given situation. Acknowledgment: We gratefully acknowledge the assistance of Mr. Zolton k’uhasz, medical illustrator, of Mr. Trent Wells of Mechanical Developments Company, in making the depressed fracture elevator, and of the neurosurgical residents at Los Angeles County (ienera1 Hospital in the management of patients. REFERENCES 1. GORDY. I'.D. Pediatric h’eurosurgery. p. X4. Edited by Jackson, I. J. and Thompson, R. K. Springfield, Ill., 1959. Charles C Thomas. 2. INGRAHAM, F. D. and MATSON, D. D. Seurosurgery of Infancy and Childhood, p. 450. Springfield, Ill., 1954. Charles C Thomas.