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Growing fracture of the orbital roof
ELSEVIER
Trauma
GROWING ORBITAL
FRACTURE ROOF
OF THE
Zain Alabedeen B. Jamjoom, M.D. Division of Neurosurgery, Security Forces Hospital, Riyadh, Saudi Arabia
Jamjoom ZAEL Growing fracture of the orbital roof. Surg Neurol 1997;48:184-8.
head injury and demonstrate the diagnostic value of magnetic resonance imaging (MRI) in such cases.
BACKGROUND Growing fractures rarely arise in the skull base, and their pathogenesis and treatment are still debated. METHODS
The clinical and radiologic findings of a growing fracture involving the orbital roof in a 5-year-old boy are presented and the relevant literature is reviewed. RESULTS
The clinical picture of growing fracture of the orbital roof is dominated by ocular symptoms such as diplopia, eyelid swelling, and displaced eye globe. Computed tomography scan is excellent for demonstrating the bony defect in the orbital roof while magnetic resonance imaging is more sensitive in showing the intraorbital extension of the leptomeningeal cyst. Frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Craniotomy with direct repair of the dural and bone defects is the treatment of choice. CONCLUSION Growing fracture of the orbital roof may complicate minor head injury and should be considered in the differentiated diagnosis in cases of persistent ocular symptoms. 0 1997 by Elsevier Science inc. KEY
WORDS
Head trauma, orbit, growing fracture, cerebrospinal fluid cyst.
S
kull fractures that continue to enlarge after the initial trauma are rare, accounting for 0.6% of all skull fractures in one large series [9]. They are mostly located in the cranial convexity [8], but may occasionally develop in the skull base [ 121. In this report, the author describes a case of a growing fracture involving the orbital roof. To the best of the author’s knowledge, only one similar case has so far been reported in the pertinent literature [2]. The aim of this report is to draw attention to this rare complication of what was considered to be a mild Address reprint requests to: Zain Alabedeen B. Jamjoom, M.D., Division of Neurosurgery, Security Forces Hospital, P. 0. Box 3643, Riyadh 11481, Saudi Arabia. Received May 15, 1996; accepted July 18, 1996. 0090-3019/97/$17.00 PI1 s0090-3019(96)00377-1
CASE
REPORT
This S-year-old boy was first seen in January 1994 when he was brought to the emergency room shortly after falling down stairs. He had a brief loss of consciousness and vomited once. On examination, he was alert and crying. His vital signs and neurologic status were within normal limits. There was, however, a marked swelling of the left upper eyelid and brow with some blood in the nostrils. A detailed ophthalmologic examination confirmed that both eyes were intact. Plain X ray of the skull revealed a linear fracture of the left frontal bone reaching down to the orbital rim (Figure 1). On computed tomography (CT) scan, there was soft tissue swelling around the left orbit. The frontal fracture was found to extend along the orbital roof with blood in the ethmoidal cells, some air inclusion in the muscular cone of the left eye, and an area suggestive of a small left frontobasal brain contusion (Figure 2). The patient was kept in the hospital for 2 days after which he was discharged in a stable condition with his left eyelid hematoma resolving. Thereafter, he was seen at 6-12-week intervals in the neurosurgical outpatient clinic, He complained of occasional double vision and his left upper eyelid continued to be slightly swollen with a mild downward displacement of the left eye globe. A follow-up CT scan 5 months after the fall disclosed an intracranial, well circumscribed and hypodense structure in the left frontobasal region, suggestive of a posttraumatic cerebrospinal fluid (CSF) cyst, and a well demarcated bony defect in the left orbital roof (Figure 3). On MRI, the left frontobasal CSF cyst was shown to extend into the orbit through the bone defect in the orbital roof (Figure 4). The patient was readmitted in September 1994 655 Avenue
0 1997 by Elsevier Science Inc. of the Americas, New York, NY 10010
Surg Neurol 1997:48:184-8
Growing Fracture of the Orbital Roof
185
a defect measuring 2 x 1 cm involving the frontobasal dura and orbital roof. The dural edges were released’ along the bony defect by extradural dissection. A periosteal flap was used to reconstruct the frontoorbital dura. The bony defect was closed with a flat piece of commercially homologous kiel bone. The postoperative recovery was uneventful and the patient was discharged 7 days postoperatively. On follow-up examination 2 months later, he was asymptomatic and the left eyelid swelling had disappeared. A coronal CT scan performed 18 months postoperatively showed complete resolution of the left frontobasal CSF cyst and good uptake of the bone graft within the orbital roof (Figure 5).
DISCUSSION
Plain anteroposterior skull X ray showing a linear fracture in left frontal region reaching down to the orbital ridge (arrowheads).
and elective left frontal craniotomy was performed. The frontal bone was adherent to the underlying dura. Severe adhesions were also present between dura and brain. The frontoorbital gyri showed gliotic changes and were mostly replaced by a CSF containing cyst that opened into the orbit through
Growing skull fracture has been reported under different designations since the early 1800s [ 71. The term leptomeningeal cyst [3] has been used synonymously and it refers to the commonly associated cystic fluid collection at the site of the fracture. Other names, such as cephalohydrocele [13], and posttraumatic porencephaly [ 11, describe other pathologic findings that may be encountered within the fracture, such as herniation of brain and ventricle and parenchymal brain cysts. The pathogenesis of growing skull fractures is still debated. The most widely accepted concept postulates the coexistence of two factors: (1) disruption of the underlying dura, and (2) an outward driving force that can be generated by cerebral edema or contusion, hydrocephalus or other intra-
Emergency axial CT scans showing a linear fracture extending along the roof of the left orbit (arrowheads) (A); with blood in the ethmoidal cells and some air collection within the ocular muscles cone (B); and an area suggestive of brain contusion in left frontal region (asterisk) (C).
186
Surg Neurol 1997;48:184-8
Jamjoom
Follow-up CT scan 5 months after the injury showing a well defined cerebrospinal fluid (CSF) containing cystic lesion in the left frontal region (asterisk) (A): in addition, there is a well circumscribed bone defect in the roof of the left orbit (arrowheads) (B).
cranial fluid collections, neoplasm, or even a normally growing brain [5,15]. The fact that the majority (90%) of the patients with growing skull fractures are children below the age of three years
1 Coronal T,-weighted magnetic resonance image LI showing that frontobasal CSF cyst (arrowheads) extends also into the orbit (arrow).
[7,8] suggests that such distraction force is more effective on young skull bone that is malleable and still has some intrinsic growth potential. Patients with a growing skull fracture typically present with a scalp swelling or palpable skull defect evolving after a head injury. Other common presenting symptoms and signs include focal neurologic deficits, raised intracranial pressure, and seizures [8]. However, when the orbital roof is affected, as in the present case, the clinical picture is predominated by ocular symptoms, such as diplopia, swollen eyelid, displaced globe, and restricted eye movement [2]. The diagnosis of a growing skull fracture is readily made on serial X rays demonstrating progressive widening of a fracture line with undulating margins. A basal fracture may not be detected without a CT scan. In addition, CT scan and MRl are indispensable in elucidating the type and extent of any associated intracranial injury. Our present case confirms that MRI is a more sensitive tool in delineating intraorbital pathologies than CT scan. While it was not possible to identify the CSF cyst within the orbital fat on CT scan, this lesion was well delineated on the TX-weighted MR images, due to the difference in the T, relaxation times for water and fat. Growing fractures tend to run a progressive course in the early period after the initial trauma, and during this period patients may exhibit clinical aspects of raised intracranial pressure [8]. This active phase is often followed by a stage of stabilization during which the condition remains either
Surg Neurol 1997;48:184-8
187
Coronal Ia months demonstrating tion and graft bital
unchanged or shows only a slow and mild deterioration. Spontaneous healing is generally considered
to be rare [lo]. The goal of treatment of a growing fracture is to close the dural and bone defects. Because the dural edges are often retracted for a long distance under the bone, extensive removal of bone around the defect may be necessary for circumferential visualization of the dural edges [4,8]. The author
found it
more convenient to elevate a large bone flap around the cranial defect. This procedure not only gives a wide exposure of the dural edges, but also permits associated intracranial lesions to be visualized in full extension by simple turning of a dural flap. Leptomeningeal cyst, fibrogliotic scars, and brain prolapse can be drained or excised with greater ease, often alleviating the need for additional procedures such as shunt surgery. In addition, repair of the bone defect by using methyl methacrylate proved to be much easier while the bone flap was free. For reconstruction of a small basal skull de feet, however, homologous bone graft gave, in the author’s experience, the best results. The question of whether the regressive changes (such as gliofibrosis and cyst formation) often observed intraoperatively in the underlying brain are secondary to the growing fracture, or a result of the initial head trauma has been difficult to answer. Although the minor nature of the injury and the absence of neurologic
patients traumatic
impairment
at the time of the injury
seem to favor the first hypothesis, brain
lesions
are not entirely
in many
“silent” excluded
because most of the patients did not undergo brain imaging at the time of the initial trauma. Recent data have clearly demonstrated that as many as
CT scan 18 postoperatively complete resoluof the frontobasal CSF cyst good uptake of the bone (arrowheads) over the orroof defect (arrow).
13% of patients with apparently minor head injuries had traumatic brain lesions that were not clinically detected [ 131. Furthermore, it is difficult to imagine how a head trauma could lead to an isolated tear of the tough dura without any effect on the underlying structures. The author shares, therefore, the opinion of others [6] that intracranial pathology associated with a growing fracture is most likely due to the primary trauma and plays an important role in the fracture’s pathogenesis. The author would like to than Ms. Hilda Sumandar For her excellent secretarial assistance and Mr. Abdullah Palma for preparing the medical photographs.
REFERENCES poren1. Barrett JW, Mendelsohn RA. Post-traumatic cephaly in infancy: a report of three unusual cases. J Neurosurg 1965;23:522-7. 2. Bayar MA, Iplikcioglu AC, Kokec F, Gokcek C. Growing skull fracture of the orbital roof. Surg Neurol 1994;41: 80-82. 3. Dyke CG. The roentgen-ray diagnosis of the skull and intracranial contents. In: Golden R, ed. Diagnostic roentgenology. New York: T Nelson and Sons, 1938:7. 4. Eisenberg HM, Briner RP. Growing skull fracture. In: McLaurin RL, Venes JL, Schut L, Epstein F, eds. Pediatric neurosurgery: surgery of the developing nervous system, 2nd edition. Philadelphia: WB Saunders, 1989:291-4. 5. Goldstein FP, Sakoda TH, Kepes JJ, Davidson K, Brackett CE. Enlarging skull fractures: an experimental study. J Neurosurg 1967;27:541-50. 6. Itoh H, Miwa T, Onodra Y. Growing skull fracture of childhood with reference to the importance of brain injury and its pathogenetic consideration. Child’s Brain 1977;2:116.
108
Surg Neurol 1997;48:184-8
Jamjoom
7. Lende RA, Erickson RC. Growing skull fractures of childhood. J Neurosurgery 1961;18:479-89. 8. Naim-Ur-Rahman, Jamjoom ZAB, Jamjoom AHB, Murshid WR. Growing skull fractures: classification and management. Br J Neurosurg 1994;8:667-79. 9. Ramamurthi B, Kalyanaraman S. Rationale for surgery in growing fractures of the skull. J Neurosurgery 1970; 32~42730. 10. Rothman L, Rose JS, Laster DW, Quencer R, Tenner M. The spectrum of growing skull fracture in children. Pediatrics 1976;57:26-31. 11. Sharma RR, Chandy MJ. Shunt surgery in growing skull fractures: report of two cases. Br J Neurosurg 1991;5:93-98. 12. Soule A, Whitcomb B. Extensive erosion of the base of the skull from a leptomeningeal cyst. Report of a case. Arch Neurol Psychiat 1946;55:382-7. 13. Stein SC, Ross SE. Mild head injury: a plea for routine early CT scanning. J Trauma 1992;33:11-13. 14. Tenner MS, Stein BM. Cerebral herniation in the growing fracture of the skull. Radiology 1970;94:351-5. 15. Winston K, Beatty RM, Fischer EC. Consequences of dural defects acquired in infancy. J Neurosurg 1983; 592339-46.
COMMENTARY
Whenever one sees a diastatic skull fracture in a young child, one should think about a dural tear and a subsequent leptomeningeal cyst. In this particular patient, the fracture was diastactic in the roof of the orbit. Furthermore, there was contusion in the frontal lobe overlying this fracture. In that sort of situation, one should think about a growing skull fracture. As the author points out, growing skull fractures typically occur over the convexity of the skull and in this particular patient, the dural tear was in the floor of the anterior fossa overlying the diastactic fracture in the roof of the orbit. With the appropriate repair, the patient regained a normal orbit with no disturbance in vision. Harold
J. Hoffman,
M.D., FRCSC
Division of Neurosurgery The Hospital for Sick Children Toronto, Ontario, Canada
HEN WE SEE MEN OF WORTH, WE SHOULD THINK OF EQUALING THEM; WHEN WE SEE MEN OF A CONTRARY CHARACTER, WE SHOULD TURN INWARDS AND EXAMINE OURSELVES. “THE
-CONFUCIUS CONFUCIAN
(55 l-479 ANALECTS,”
B.C.) 4: 17
Trauma
GROWING ORBITAL
FRACTURE ROOF
OF THE
Zain Alabedeen B. Jamjoom, M.D. Division of Neurosurgery, Security Forces Hospital, Riyadh, Saudi Arabia
Jamjoom ZAEL Growing fracture of the orbital roof. Surg Neurol 1997;48:184-8.
head injury and demonstrate the diagnostic value of magnetic resonance imaging (MRI) in such cases.
BACKGROUND Growing fractures rarely arise in the skull base, and their pathogenesis and treatment are still debated. METHODS
The clinical and radiologic findings of a growing fracture involving the orbital roof in a 5-year-old boy are presented and the relevant literature is reviewed. RESULTS
The clinical picture of growing fracture of the orbital roof is dominated by ocular symptoms such as diplopia, eyelid swelling, and displaced eye globe. Computed tomography scan is excellent for demonstrating the bony defect in the orbital roof while magnetic resonance imaging is more sensitive in showing the intraorbital extension of the leptomeningeal cyst. Frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Craniotomy with direct repair of the dural and bone defects is the treatment of choice. CONCLUSION Growing fracture of the orbital roof may complicate minor head injury and should be considered in the differentiated diagnosis in cases of persistent ocular symptoms. 0 1997 by Elsevier Science inc. KEY
WORDS
Head trauma, orbit, growing fracture, cerebrospinal fluid cyst.
S
kull fractures that continue to enlarge after the initial trauma are rare, accounting for 0.6% of all skull fractures in one large series [9]. They are mostly located in the cranial convexity [8], but may occasionally develop in the skull base [ 121. In this report, the author describes a case of a growing fracture involving the orbital roof. To the best of the author’s knowledge, only one similar case has so far been reported in the pertinent literature [2]. The aim of this report is to draw attention to this rare complication of what was considered to be a mild Address reprint requests to: Zain Alabedeen B. Jamjoom, M.D., Division of Neurosurgery, Security Forces Hospital, P. 0. Box 3643, Riyadh 11481, Saudi Arabia. Received May 15, 1996; accepted July 18, 1996. 0090-3019/97/$17.00 PI1 s0090-3019(96)00377-1
CASE
REPORT
This S-year-old boy was first seen in January 1994 when he was brought to the emergency room shortly after falling down stairs. He had a brief loss of consciousness and vomited once. On examination, he was alert and crying. His vital signs and neurologic status were within normal limits. There was, however, a marked swelling of the left upper eyelid and brow with some blood in the nostrils. A detailed ophthalmologic examination confirmed that both eyes were intact. Plain X ray of the skull revealed a linear fracture of the left frontal bone reaching down to the orbital rim (Figure 1). On computed tomography (CT) scan, there was soft tissue swelling around the left orbit. The frontal fracture was found to extend along the orbital roof with blood in the ethmoidal cells, some air inclusion in the muscular cone of the left eye, and an area suggestive of a small left frontobasal brain contusion (Figure 2). The patient was kept in the hospital for 2 days after which he was discharged in a stable condition with his left eyelid hematoma resolving. Thereafter, he was seen at 6-12-week intervals in the neurosurgical outpatient clinic, He complained of occasional double vision and his left upper eyelid continued to be slightly swollen with a mild downward displacement of the left eye globe. A follow-up CT scan 5 months after the fall disclosed an intracranial, well circumscribed and hypodense structure in the left frontobasal region, suggestive of a posttraumatic cerebrospinal fluid (CSF) cyst, and a well demarcated bony defect in the left orbital roof (Figure 3). On MRI, the left frontobasal CSF cyst was shown to extend into the orbit through the bone defect in the orbital roof (Figure 4). The patient was readmitted in September 1994 655 Avenue
0 1997 by Elsevier Science Inc. of the Americas, New York, NY 10010
Surg Neurol 1997:48:184-8
Growing Fracture of the Orbital Roof
185
a defect measuring 2 x 1 cm involving the frontobasal dura and orbital roof. The dural edges were released’ along the bony defect by extradural dissection. A periosteal flap was used to reconstruct the frontoorbital dura. The bony defect was closed with a flat piece of commercially homologous kiel bone. The postoperative recovery was uneventful and the patient was discharged 7 days postoperatively. On follow-up examination 2 months later, he was asymptomatic and the left eyelid swelling had disappeared. A coronal CT scan performed 18 months postoperatively showed complete resolution of the left frontobasal CSF cyst and good uptake of the bone graft within the orbital roof (Figure 5).
DISCUSSION
Plain anteroposterior skull X ray showing a linear fracture in left frontal region reaching down to the orbital ridge (arrowheads).
and elective left frontal craniotomy was performed. The frontal bone was adherent to the underlying dura. Severe adhesions were also present between dura and brain. The frontoorbital gyri showed gliotic changes and were mostly replaced by a CSF containing cyst that opened into the orbit through
Growing skull fracture has been reported under different designations since the early 1800s [ 71. The term leptomeningeal cyst [3] has been used synonymously and it refers to the commonly associated cystic fluid collection at the site of the fracture. Other names, such as cephalohydrocele [13], and posttraumatic porencephaly [ 11, describe other pathologic findings that may be encountered within the fracture, such as herniation of brain and ventricle and parenchymal brain cysts. The pathogenesis of growing skull fractures is still debated. The most widely accepted concept postulates the coexistence of two factors: (1) disruption of the underlying dura, and (2) an outward driving force that can be generated by cerebral edema or contusion, hydrocephalus or other intra-
Emergency axial CT scans showing a linear fracture extending along the roof of the left orbit (arrowheads) (A); with blood in the ethmoidal cells and some air collection within the ocular muscles cone (B); and an area suggestive of brain contusion in left frontal region (asterisk) (C).
186
Surg Neurol 1997;48:184-8
Jamjoom
Follow-up CT scan 5 months after the injury showing a well defined cerebrospinal fluid (CSF) containing cystic lesion in the left frontal region (asterisk) (A): in addition, there is a well circumscribed bone defect in the roof of the left orbit (arrowheads) (B).
cranial fluid collections, neoplasm, or even a normally growing brain [5,15]. The fact that the majority (90%) of the patients with growing skull fractures are children below the age of three years
1 Coronal T,-weighted magnetic resonance image LI showing that frontobasal CSF cyst (arrowheads) extends also into the orbit (arrow).
[7,8] suggests that such distraction force is more effective on young skull bone that is malleable and still has some intrinsic growth potential. Patients with a growing skull fracture typically present with a scalp swelling or palpable skull defect evolving after a head injury. Other common presenting symptoms and signs include focal neurologic deficits, raised intracranial pressure, and seizures [8]. However, when the orbital roof is affected, as in the present case, the clinical picture is predominated by ocular symptoms, such as diplopia, swollen eyelid, displaced globe, and restricted eye movement [2]. The diagnosis of a growing skull fracture is readily made on serial X rays demonstrating progressive widening of a fracture line with undulating margins. A basal fracture may not be detected without a CT scan. In addition, CT scan and MRl are indispensable in elucidating the type and extent of any associated intracranial injury. Our present case confirms that MRI is a more sensitive tool in delineating intraorbital pathologies than CT scan. While it was not possible to identify the CSF cyst within the orbital fat on CT scan, this lesion was well delineated on the TX-weighted MR images, due to the difference in the T, relaxation times for water and fat. Growing fractures tend to run a progressive course in the early period after the initial trauma, and during this period patients may exhibit clinical aspects of raised intracranial pressure [8]. This active phase is often followed by a stage of stabilization during which the condition remains either
Surg Neurol 1997;48:184-8
187
Coronal Ia months demonstrating tion and graft bital
unchanged or shows only a slow and mild deterioration. Spontaneous healing is generally considered
to be rare [lo]. The goal of treatment of a growing fracture is to close the dural and bone defects. Because the dural edges are often retracted for a long distance under the bone, extensive removal of bone around the defect may be necessary for circumferential visualization of the dural edges [4,8]. The author
found it
more convenient to elevate a large bone flap around the cranial defect. This procedure not only gives a wide exposure of the dural edges, but also permits associated intracranial lesions to be visualized in full extension by simple turning of a dural flap. Leptomeningeal cyst, fibrogliotic scars, and brain prolapse can be drained or excised with greater ease, often alleviating the need for additional procedures such as shunt surgery. In addition, repair of the bone defect by using methyl methacrylate proved to be much easier while the bone flap was free. For reconstruction of a small basal skull de feet, however, homologous bone graft gave, in the author’s experience, the best results. The question of whether the regressive changes (such as gliofibrosis and cyst formation) often observed intraoperatively in the underlying brain are secondary to the growing fracture, or a result of the initial head trauma has been difficult to answer. Although the minor nature of the injury and the absence of neurologic
patients traumatic
impairment
at the time of the injury
seem to favor the first hypothesis, brain
lesions
are not entirely
in many
“silent” excluded
because most of the patients did not undergo brain imaging at the time of the initial trauma. Recent data have clearly demonstrated that as many as
CT scan 18 postoperatively complete resoluof the frontobasal CSF cyst good uptake of the bone (arrowheads) over the orroof defect (arrow).
13% of patients with apparently minor head injuries had traumatic brain lesions that were not clinically detected [ 131. Furthermore, it is difficult to imagine how a head trauma could lead to an isolated tear of the tough dura without any effect on the underlying structures. The author shares, therefore, the opinion of others [6] that intracranial pathology associated with a growing fracture is most likely due to the primary trauma and plays an important role in the fracture’s pathogenesis. The author would like to than Ms. Hilda Sumandar For her excellent secretarial assistance and Mr. Abdullah Palma for preparing the medical photographs.
REFERENCES poren1. Barrett JW, Mendelsohn RA. Post-traumatic cephaly in infancy: a report of three unusual cases. J Neurosurg 1965;23:522-7. 2. Bayar MA, Iplikcioglu AC, Kokec F, Gokcek C. Growing skull fracture of the orbital roof. Surg Neurol 1994;41: 80-82. 3. Dyke CG. The roentgen-ray diagnosis of the skull and intracranial contents. In: Golden R, ed. Diagnostic roentgenology. New York: T Nelson and Sons, 1938:7. 4. Eisenberg HM, Briner RP. Growing skull fracture. In: McLaurin RL, Venes JL, Schut L, Epstein F, eds. Pediatric neurosurgery: surgery of the developing nervous system, 2nd edition. Philadelphia: WB Saunders, 1989:291-4. 5. Goldstein FP, Sakoda TH, Kepes JJ, Davidson K, Brackett CE. Enlarging skull fractures: an experimental study. J Neurosurg 1967;27:541-50. 6. Itoh H, Miwa T, Onodra Y. Growing skull fracture of childhood with reference to the importance of brain injury and its pathogenetic consideration. Child’s Brain 1977;2:116.
108
Surg Neurol 1997;48:184-8
Jamjoom
7. Lende RA, Erickson RC. Growing skull fractures of childhood. J Neurosurgery 1961;18:479-89. 8. Naim-Ur-Rahman, Jamjoom ZAB, Jamjoom AHB, Murshid WR. Growing skull fractures: classification and management. Br J Neurosurg 1994;8:667-79. 9. Ramamurthi B, Kalyanaraman S. Rationale for surgery in growing fractures of the skull. J Neurosurgery 1970; 32~42730. 10. Rothman L, Rose JS, Laster DW, Quencer R, Tenner M. The spectrum of growing skull fracture in children. Pediatrics 1976;57:26-31. 11. Sharma RR, Chandy MJ. Shunt surgery in growing skull fractures: report of two cases. Br J Neurosurg 1991;5:93-98. 12. Soule A, Whitcomb B. Extensive erosion of the base of the skull from a leptomeningeal cyst. Report of a case. Arch Neurol Psychiat 1946;55:382-7. 13. Stein SC, Ross SE. Mild head injury: a plea for routine early CT scanning. J Trauma 1992;33:11-13. 14. Tenner MS, Stein BM. Cerebral herniation in the growing fracture of the skull. Radiology 1970;94:351-5. 15. Winston K, Beatty RM, Fischer EC. Consequences of dural defects acquired in infancy. J Neurosurg 1983; 592339-46.
COMMENTARY
Whenever one sees a diastatic skull fracture in a young child, one should think about a dural tear and a subsequent leptomeningeal cyst. In this particular patient, the fracture was diastactic in the roof of the orbit. Furthermore, there was contusion in the frontal lobe overlying this fracture. In that sort of situation, one should think about a growing skull fracture. As the author points out, growing skull fractures typically occur over the convexity of the skull and in this particular patient, the dural tear was in the floor of the anterior fossa overlying the diastactic fracture in the roof of the orbit. With the appropriate repair, the patient regained a normal orbit with no disturbance in vision. Harold
J. Hoffman,
M.D., FRCSC
Division of Neurosurgery The Hospital for Sick Children Toronto, Ontario, Canada
HEN WE SEE MEN OF WORTH, WE SHOULD THINK OF EQUALING THEM; WHEN WE SEE MEN OF A CONTRARY CHARACTER, WE SHOULD TURN INWARDS AND EXAMINE OURSELVES. “THE
-CONFUCIUS CONFUCIAN
(55 l-479 ANALECTS,”
B.C.) 4: 17