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Elevation of depressed skull fracture with a breast pump
3 O0
Brief clinical and laboratory observations
The Journal of Pediatrics August 1970
"spontan" Regressivem Verlauf, Dermatologica 120: 35, 1960. 5. Greenberg, B., Rosenthal, I., and Falk, G. S.: Electron microscopy of human tumors secreting catecholamines: Correlation with biochemical data, J. Neuropath. Exp. Neurol. 28: 475, 1969. 6. Misugi, K., Misubi, N., and Newton, W. A.: Fine structural study of neuroblastoma, ganglioneuroblastorna, and pheochromocytoma, Arch. Path. 86: 160, 1968.
7. Grillo, iV[. A., and Palay, S. L.: Granule containing vesicles in the autonomic nervous system, in Breese, S. S., editor: Fifth International Congress of Electron-Microscopy, Philadelphia, 1962, Academic Press, Inc. 8. Nelson, J. S., and Wakefield, P. L.: The cellular localization of catecholamines in frozendried cryostat sections of the brain and autonomic nervous system, J. Neuropath. Exp. Neurol. 27: 221, 1968.
Elevation of depressed skull fracture with a breast pump
in circumference, the chest 35 cm. There was marked overriding of sutures, with discoloration of the scalp over the depression but no crepitus. Craniotabes was not present. The infant was hyperirritable, with a high-pitched cry and frequent tremors of all extremities. Respirations were irregular, but color was good. Radiographs showed marked depression of the left side of the skull (Fig. 1). An interruption in ,the continuity of the cortex of the parietal bone, noted on lateral films, may have represented a fracture line or a parietal fissure. The feasibility of elevating the depression by suction was discussed with the consulting neurosurgeon, who found no contraindication to its attempt. Accordingly, we began a search for appropriate equipment that could apply negative pressure over a wide enough area. Finally we thought of the Davol hand breast pump, whose suction bell measures 6 ~ cm. in diameter. Applying petroleum jelly to the edges for a tighter seal, we used gentle suction over the depressed area; within 15 minutes it had been elevated completely. Repeat radiographs of the skull taken several hours after the initial films demonstrated the efficacy of this procedure (Fig. 9). The infant did well; signs of hyperirritability disappeared, and she was discharged with her mother on the fifth day. Blood studies, including routine hemogram and serum bilirubin and calcium values, were all within the normal ranges. The infant is now one year of age and is growing and developing satisfactorily. Head measurements have been well within normal limits; she is alert and responsive. Repeat skull radiographs have been normal. An electroencephalogram on July 3, 1969, was interpreted as mildly abnormal, showing frontal asymmetry with slightly less regularity on the left. The electroencephalogram was repeated Feb. 14, 1970, when the infant was 9 ~ months of age.
Gloria Ogur Schrager, M.D., F.A.A.P. ~r
N. J.
H E A D I N J u R Y is a c o m m o n perinatal complication, particularly in primiparity with forceps delivery. M a n y of these head injuries, such as c e p h a l o h e m a t o m a a n d linear fracture, are relatively innocuous, but depressed fractures have a more serious implication. A l t h o u g h some believe that these " p i n g - p o n g ball" type fractures m a y heal without treatment, Schaffer 1 believes that all depressed fractures should be repaired immediately. T h e following case report d e m o n strates a simple, a t r a u m a f i c procedure used to elevate a massive skull depression. CASE R E P O R T Patient C. B. (Overlook Hospital Case No. 138903) was a Caucasian female infant born by breech forceps delivery on April 14, 1969 to a primipara after a labor of 9 hours and 22 minutes. Birth weight was 4 kilograms. Onset of crying and respirations was delayed; the one minute Apgar score was 5. A linear depression of the parietal bone measuring 6 ,by 3 cm. and 1~2 cm. in depth was noted. The head was 36.5 cm. Address: 1020 Summit Ave., Westfield, N. ]. 07090.
Volume 77 Number 2
Fig. 1. Skull films demonstrating marked depression of left parietal bone sustained during breech forceps delivery. The record was considered to be within normal limits, with no significant asymmetry. DISCUSSION Schaffer 1 describes depressed fracture in the newborn infant as an inward buckling of one of the membranous bones, usually a parietal, with or without a visible fracture at the depth of concavity. This case report would fit his definition whether one interprets the lateral skull radiograph as showing fracture or fissure, a normal variant. T h e question is academic, since the danger with or without a visible fracture line is caused by the pressure of the depressed bone on the underlying cerebrum. This pressure can give rise to an epileptogenic focus or other signs of dysfunctionY R a y n o r and Parsa a have described a nonsurgical m e t h o d of elevating a depressed skull fracture by placing a thumb on opposite margins of the depression and pressing gently but firmly towards the middle. I t is doubtful whether this technique would have worked for this larger depression, but the principle of nonsurgical elevation of depressed fractures should be heartily endorsed.
Brief clinical and laboratory observations
301
Fig. 2. Skull films taken several hours later, demonstrating elevation of depression after suction applied to area. T h e procedure usually recommended, surgical elevation with a sharp hook, 4 requires m u c h more manipulation of an already traumatized infant with attendant increase in morbidity and death. Nonsurgical elevation can be done in the nursery and is technically m u c h simpler and less traumatic. SUMMARY
A depression of the left parietal bone measuring 6 by 3 cm. and 1 ~ cm. in depth, sustained during breech forceps delivery, was elevated by suction applied by a h a n d breast pump. Nonsurgical elevation of depressed skull fracture in the newborn infant is technically feasible and should be attempted before operative intervention is considered. REFERENCES
1. Schaffer, A. J.: Diseases of the Newborn, ed. 2, Philadelphia, 1965, W. B. Saunders Company. 2. Ingraham, F. D., and Matson, D. D.: Neurosurgery of infancy and childhood, Springfield, Ill., 1954, Charles C Thomas, Publisher. 3. Raynor, R., and Parsa, M. : Nonsurgical elevation of depressed skull fracture in an infant, J. PEDIAZ.72: 262, 1968. 4. Jackson, I. J., and Thompson, R. K.: Pediatrlc neurology, Springfield, Ill., 1959, Charles C Thomas, Publisher.
Brief clinical and laboratory observations
The Journal of Pediatrics August 1970
"spontan" Regressivem Verlauf, Dermatologica 120: 35, 1960. 5. Greenberg, B., Rosenthal, I., and Falk, G. S.: Electron microscopy of human tumors secreting catecholamines: Correlation with biochemical data, J. Neuropath. Exp. Neurol. 28: 475, 1969. 6. Misugi, K., Misubi, N., and Newton, W. A.: Fine structural study of neuroblastoma, ganglioneuroblastorna, and pheochromocytoma, Arch. Path. 86: 160, 1968.
7. Grillo, iV[. A., and Palay, S. L.: Granule containing vesicles in the autonomic nervous system, in Breese, S. S., editor: Fifth International Congress of Electron-Microscopy, Philadelphia, 1962, Academic Press, Inc. 8. Nelson, J. S., and Wakefield, P. L.: The cellular localization of catecholamines in frozendried cryostat sections of the brain and autonomic nervous system, J. Neuropath. Exp. Neurol. 27: 221, 1968.
Elevation of depressed skull fracture with a breast pump
in circumference, the chest 35 cm. There was marked overriding of sutures, with discoloration of the scalp over the depression but no crepitus. Craniotabes was not present. The infant was hyperirritable, with a high-pitched cry and frequent tremors of all extremities. Respirations were irregular, but color was good. Radiographs showed marked depression of the left side of the skull (Fig. 1). An interruption in ,the continuity of the cortex of the parietal bone, noted on lateral films, may have represented a fracture line or a parietal fissure. The feasibility of elevating the depression by suction was discussed with the consulting neurosurgeon, who found no contraindication to its attempt. Accordingly, we began a search for appropriate equipment that could apply negative pressure over a wide enough area. Finally we thought of the Davol hand breast pump, whose suction bell measures 6 ~ cm. in diameter. Applying petroleum jelly to the edges for a tighter seal, we used gentle suction over the depressed area; within 15 minutes it had been elevated completely. Repeat radiographs of the skull taken several hours after the initial films demonstrated the efficacy of this procedure (Fig. 9). The infant did well; signs of hyperirritability disappeared, and she was discharged with her mother on the fifth day. Blood studies, including routine hemogram and serum bilirubin and calcium values, were all within the normal ranges. The infant is now one year of age and is growing and developing satisfactorily. Head measurements have been well within normal limits; she is alert and responsive. Repeat skull radiographs have been normal. An electroencephalogram on July 3, 1969, was interpreted as mildly abnormal, showing frontal asymmetry with slightly less regularity on the left. The electroencephalogram was repeated Feb. 14, 1970, when the infant was 9 ~ months of age.
Gloria Ogur Schrager, M.D., F.A.A.P. ~r
N. J.
H E A D I N J u R Y is a c o m m o n perinatal complication, particularly in primiparity with forceps delivery. M a n y of these head injuries, such as c e p h a l o h e m a t o m a a n d linear fracture, are relatively innocuous, but depressed fractures have a more serious implication. A l t h o u g h some believe that these " p i n g - p o n g ball" type fractures m a y heal without treatment, Schaffer 1 believes that all depressed fractures should be repaired immediately. T h e following case report d e m o n strates a simple, a t r a u m a f i c procedure used to elevate a massive skull depression. CASE R E P O R T Patient C. B. (Overlook Hospital Case No. 138903) was a Caucasian female infant born by breech forceps delivery on April 14, 1969 to a primipara after a labor of 9 hours and 22 minutes. Birth weight was 4 kilograms. Onset of crying and respirations was delayed; the one minute Apgar score was 5. A linear depression of the parietal bone measuring 6 ,by 3 cm. and 1~2 cm. in depth was noted. The head was 36.5 cm. Address: 1020 Summit Ave., Westfield, N. ]. 07090.
Volume 77 Number 2
Fig. 1. Skull films demonstrating marked depression of left parietal bone sustained during breech forceps delivery. The record was considered to be within normal limits, with no significant asymmetry. DISCUSSION Schaffer 1 describes depressed fracture in the newborn infant as an inward buckling of one of the membranous bones, usually a parietal, with or without a visible fracture at the depth of concavity. This case report would fit his definition whether one interprets the lateral skull radiograph as showing fracture or fissure, a normal variant. T h e question is academic, since the danger with or without a visible fracture line is caused by the pressure of the depressed bone on the underlying cerebrum. This pressure can give rise to an epileptogenic focus or other signs of dysfunctionY R a y n o r and Parsa a have described a nonsurgical m e t h o d of elevating a depressed skull fracture by placing a thumb on opposite margins of the depression and pressing gently but firmly towards the middle. I t is doubtful whether this technique would have worked for this larger depression, but the principle of nonsurgical elevation of depressed fractures should be heartily endorsed.
Brief clinical and laboratory observations
301
Fig. 2. Skull films taken several hours later, demonstrating elevation of depression after suction applied to area. T h e procedure usually recommended, surgical elevation with a sharp hook, 4 requires m u c h more manipulation of an already traumatized infant with attendant increase in morbidity and death. Nonsurgical elevation can be done in the nursery and is technically m u c h simpler and less traumatic. SUMMARY
A depression of the left parietal bone measuring 6 by 3 cm. and 1 ~ cm. in depth, sustained during breech forceps delivery, was elevated by suction applied by a h a n d breast pump. Nonsurgical elevation of depressed skull fracture in the newborn infant is technically feasible and should be attempted before operative intervention is considered. REFERENCES
1. Schaffer, A. J.: Diseases of the Newborn, ed. 2, Philadelphia, 1965, W. B. Saunders Company. 2. Ingraham, F. D., and Matson, D. D.: Neurosurgery of infancy and childhood, Springfield, Ill., 1954, Charles C Thomas, Publisher. 3. Raynor, R., and Parsa, M. : Nonsurgical elevation of depressed skull fracture in an infant, J. PEDIAZ.72: 262, 1968. 4. Jackson, I. J., and Thompson, R. K.: Pediatrlc neurology, Springfield, Ill., 1959, Charles C Thomas, Publisher.