Mathematical analysis of fracture configuration in predicting outcome in complex anterior skull base trauma.

Craniofacial trauma involving the anterior skull base produces a heterogenous injury with variance in fracture pattern, complexity and outcome. Variance is influenced by the biomechanical properties of the craniofacial construct and by the magnitude and vector of the impacting energy. Fractal dimension and other metrics applied to individual fracture patterns allows quantification of fracture complexity and severity, which can be used to correlate with neurological outcome. Frontobasal fractures from 81 patients admitted to two UK major trauma centres were analysed. Patients were divided into two groups: those with anteriorly-based vectors of impact and those with laterally-based vectors. Osseous disruption was quantified by: fractal dimension, fracture length, number of termini, and number of nodes, and then compared with neurological outcome using first recorded Glasgow Coma Score (GCS), and requirement for intubation. As fracture length increased, fractures from anterior impacts became more complex and reticulated compared with lateral impacts; fractal dimension also increased more rapidly for anterior impacts. Longer fracture length in both groups was associated with a significantly lower GCS, and increased requirement for intubation (p < 0.001 and p < 0.001 respectively). Fracture propagation and severity of head injury was different in anterior-directed trauma compared to lateral-directed trauma. Consequently, we suggest that the central region of the anterior skull base acts to primarily absorb impact force thereby behaving as a protective ' crumple zone ' . In severe mechanisms the protective mechanism is exceeded and the fracture length tended to that of the lateral group worsening prognosis.

Olfactory and Gustatory Function in Patients With Different Types of Maxillofacial Trauma.

OBJECTIVES/HYPOTHESIS: To investigate olfactory and gustatory function in patients with maxillofacial trauma and associated fractures. STUDY DESIGN: Retrospective cohort study. METHODS: Olfactory and gustatory function was assessed psychophysically in 124 patients who had sustained maxillofacial trauma with an associated fracture. Five groups were defined based on the fracture type: Le Fort, mandibular, nasal, orbital, and zygomatic. Olfaction was measured with Sniffin' Sticks (threshold, discrimination, identification [TDI] score) and gustation with the taste spray method. Patients self-rated olfactory and gustatory function on a visual analog scale prior to formal testing. RESULTS: Ten out of 124 patients were found to be anosmic (8%), with half of them found in the Le Fort (skull base) group. The Le Fort fracture group had significantly lower olfactory function than other fracture types (TDI score = 22.4 ± 10.7; P = .01; possible range = 1-48). The mean gustatory spray test score was 3.82 ± 0.4 (possible range = 0-4) without any intergroup differences. Self-rated olfactory function showed a correlation with the measured scores (r = 0.61, P < .001) across all groups. CONCLUSIONS: The present data show a significant effect of maxillofacial fracture type on the development of anosmia. Maxillofacial fractures involving the skull base, such as Le Fort fractures, are more likely to cause permanent smell loss, whereas the other fracture types are rarely associated with anosmia. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E331-E337, 2021.

Dynamic changes of facial skeletal fractures with time.

To investigate the characteristics of imaging changes with time of facial fractures, patients with facial fractures who had computed tomographic scan were enrolled including 500 patients who were divided into six groups based on the time of scanning: super early (<3 d), early (4-7 d), early-to-medium (8-14 d), medium (15-21d), medium-to-late (22d-2 months) and late stage (>2 months). The data were compared and analyzed. Forty two patients with frontal bone fractures had high-energy impact as the reason of fractures. The fracture line was clear and sharp within one week but blunt and sclerotic due to bone absorption at 2-3 weeks, and might exist for a long time. All patients had soft tissue swelling and paranasal sinus effusion at 1-2 weeks after injury. Air might gather in the adjacent soft tissues and/or intracranially within 3 days of injury if the fracture involved the frontal or other sinuses. Twelve of the 42 patients (28.6%) had intracranial hematoma, and five (11.9%) had epidural effusion. Subarachnoid hemorrhage was mostly absorbed within one week while epidural hematoma was completely absorbed over 3 weeks. Significant changes (P < 0.05) in the fracture lines, effusion of paranasal sinuses, soft tissue swelling and pneumocephalus were observed during the study period. For patients with medial orbital wall fractures, the fracture line was sharp and clear at early stages with concurrent sphenoid sinus effusion, and the fracture line became depressed 3 weeks later with disappearance of sphenoid sinus effusion. Significant changes (P < 0.05) were observed in the sharp fracture line, soft tissue swelling, sphenoid sinus effusion and smooth depression at fracture sites. For nasal fractures, the fracture line was sharp and clear at early stages with concurrent soft tissue swelling which disappeared one week later. The fracture line became smooth three weeks later. A significant (P < 0.05) difference was demonstrated in the changes of fracture line and soft tissue swelling with time. In conclusion, facial fractures have some dynamic alterations with time and identification of these characteristics may help reaching a correct clinical diagnosis with regard to fracture severity and time.

Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study.

Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.

Skull fracture prediction through subject-specific finite element modelling is highly sensitive to model parameters.

Reliable computer models are needed for a better understanding of the physical mechanisms of skull fracture in accidental hits, falls, bicycle - motor vehicle & car accidents and assaults. The performance and biofidelity of these models depend on the correct anatomical representation and material description of these structures. In literature, a strain energy criterion has been proposed to predict skull fractures. However, a broad range of values for this criterion has been reported. This study investigates if the impactor orientation, scalp thickness and material model of the skull could provide us with insight in the influencing factors of this criterion. 18 skull fracture experiments previously performed in our research group were reproduced in finite element simulations. Subject-specific skull geometries were derived from medical images and used to create high-quality finite element meshes. Based on local Hounsfield units, a subject-specific isotropic material model was assigned. The subject-specific models were able to predict fractures who matched visually with the corresponding experimental fracture patterns and provided detailed fracture patterns. The sensitivity study showed that small variations in impactor positioning as well as variations of the local geometry (frontal-temporal-occipital) strongly influenced the skull strain energy. Subject-specific modelling leads to a more accurate prediction of the force-displacement curve. The average error of the peak fracture force for all the 18 cases is 0.4190 for the subject-specific and 0.4538 for the homogeneous material model, for the displacement; 0.3368 versus 0.3844. But it should be carefully interpreted as small variations in the computational model significantly influence the outcome.

The potential protective effects of temporal bone pneumatization: A shock absorber in temporal bone fracture.

OBJECTIVES: We hypothesize that when temporal bone fractures occur, the pneumatic cells in the temporal bone are able to absorb most of the impact force during a traumatic event. This study aims to correlate the degree of pneumatization of the temporal bone with the severity of temporal bone fracture (TBF). METHODS: Charts and computed tomography scans representing 54 TBFs, diagnosed from 2012 to 2017 at a single tertiary hospital, were retrospectively reviewed. Temporal bone pneumatization (TBP) in the petrous apex and mastoid region was evaluated using previously published classification systems. TBP classifications and fracture types were correlated with TBF complications such as sensorineural hearing loss (SNHL), facial nerve palsy (FNP), and vestibular dysfunction. RESULTS: Patients with increased pneumatization of the temporal bone had significantly fewer and less severe SNHL. SNHL more strongly correlated with the degree of pneumatization in the mastoid (P = 0.005) than that in the petrous apex (P = 0.024). On the other hand, the degree of TBP correlated poorly with FNP and vestibular dysfunction. However, the mastoid hypopneumatization demonstrated significant correlation with otic-capsule violations (P = 0.002). Fractures with otic-capsule violation were 4 times more likely to have vestibular dysfunction (P = 0.043) and 3 times more likely to have SNHL (P = 0.006). FNP was not associated with otic-capsule violating fractures but was 3.5 times more common in comminuted fractures (P = 0.025). CONCLUSIONS: The degree of temporal bone pneumatization was negatively correlated to the incidence of otic-capsule violation and the severity of hearing impairment in patients with temporal bone fracture. This study substantiated the potential protective effect of temporal bone pneumatization in TBFs.

A coupled physical-computational methodology for the investigation of short fall related infant head impact injury.

Head injury in childhood is the most common cause of death or permanent disability from injury. However, insufficient understanding exists of the response of a child's head to injurious loading scenarios to establish cause and effect relationships to assist forensic and safetly investigations. Largely as a result of a lack of availability of paediatric clinical and Post-Mortem-Human-Surrogate (PMHS) experimental data, a new approach to infant head injury experimentation has been developed. A coupled-methodology, combining a physical infant head surrogate, producing "real world" global, regional and localised impact response data and a computational Finite-Element (FE-head) model was created and validated against available PMHS and physical model global impact response data. Experimental impact simulations were performed to investigate regional and localised injury vulnerability. Different regions of the head produced accelerations significantly greater than those calculated using the currently available method of measuring the global, whole head response. The majority of material strain was produced within the relatively elastic suture and fontanelle regions, rather than the skull bones. A subsequent parametric analysis was conducted to provide a correlation between fall height and areas of maximum-stress-response and fracture-risk-probability. The FE-head was further applied to investigating fracture risk, simulating injurious PMHS impacts and a good qualitative match was observed. The FE-head shows significant potential for the study of infant head injury and is anticipated to be a motivating tool for the improvement of head injury understanding across a range of potentially injurious head loading scenarios.

Risk of Ischemic Stroke After a Facial Bone Fracture in Elderly Patients.

BACKGROUND: Ischemic stroke is a major disease in our aging society, and the incidence of facial bone fractures among the elderly has increased. However, there have been few studies evaluating stroke after facial bone fractures. The purpose of this study was to investigate the frequency and risk of stroke after facial bone fractures. METHODS: This study included patients 65 years or older with a diagnosis of facial bone fracture (study group) and patients who had previously undergone plastic surgery procedures such as mass excisions or cosmetic surgery (control group) from 2006 to 2015. We evaluated the incidence of new-onset ischemic stroke and its associated risk factors during a 1-year follow-up period. Patients were excluded if they had a history of stroke or if they were lost to follow-up during the course of the study period. RESULTS: There were no demographic differences between the 2 groups except in age. According to the hazard ratio, the study group had a significantly higher risk of ischemic stroke than did the control group during the follow-up period. There was an identified interaction between the sexes. Only the women in our study group had an increased risk of ischemic stroke that was statistically significant. After adjusting for the risk factors, the increased stroke risk in patients in the study group persisted at about the same level as in the unadjusted analysis. Regarding the stroke-free survival rates, the curve also showed that the study group had a significantly lower 1-year stroke-free survival rate. CONCLUSIONS: Facial bone fractures are associated with increased risk of stroke at 1-year follow-up among elderly patients, particularly women.

Creating a human head finite element model using a multi-block approach for predicting skull response and brain pressure.

To better understand head injuries, human head finite element (FE) models have been reported in the literature. In scenarios where the head is directly impacted and measurements of head accelerations are not available, a high-quality skull model, as well as a high-quality brain model, is needed to predict the effect of impact on the brain through the skull. Furthermore, predicting cranial bone fractures requires comprehensively validated skull models. Lastly, high-quality meshes for both the skull and brain are needed for accurate strain/stress predictions across the entire head. Hence, we adopted a multi-block approach to develop hexahedral meshes for the brain, skull, and scalp simultaneously, a first approach in its kind. We then validated our model against experimental data of brain pressures (Nahum et al., 1977 ) and comprehensive skull responses (Yoganandan et al., 1995 , Yoganandan et al., 2004 , and Raymond et al., 2009 ). We concluded that a human head FE model was developed with capabilities to predict blunt- and ballistic-impact-induced skull fractures and pressure-related brain injuries.

Anatomical Thin Titanium Mesh Plate Structural Optimization for Zygomatic-Maxillary Complex Fracture under Fatigue Testing.

This study performs a structural optimization of anatomical thin titanium mesh (ATTM) plate and optimal designed ATTM plate fabricated using additive manufacturing (AM) to verify its stabilization under fatigue testing. Finite element (FE) analysis was used to simulate the structural bending resistance of a regular ATTM plate. The Taguchi method was employed to identify the significance of each design factor in controlling the deflection and determine an optimal combination of designed factors. The optimal designed ATTM plate with patient-matched facial contour was fabricated using AM and applied to a ZMC comminuted fracture to evaluate the resting maxillary micromotion/strain under fatigue testing. The Taguchi analysis found that the ATTM plate required a designed internal hole distance to be 0.9 mm, internal hole diameter to be 1 mm, plate thickness to be 0.8 mm, and plate height to be 10 mm. The designed plate thickness factor primarily dominated the bending resistance up to 78% importance. The averaged micromotion (displacement) and strain of the maxillary bone showed that ZMC fracture fixation using the miniplate was significantly higher than those using the AM optimal designed ATTM plate. This study concluded that the optimal designed ATTM plate with enough strength to resist the bending effect can be obtained by combining FE and Taguchi analyses. The optimal designed ATTM plate with patient-matched facial contour fabricated using AM provides superior stabilization for ZMC comminuted fractured bone segments.

Bilateral Post-Traumatic Facial Paralysis That Contains Longitudinal and Transverse Temporal Fracture.

Acute bilateral post-traumatic facial paralysis is rare in the literature. Post-traumatic facial paralysis is frequently accompanied transverse fractures of temporal more. The incidence of acute bilateral post-traumatic facial paralysis has been reported as 1 to 5 per million in the literature. Trauma and concurrent facial paralysis are usually in the same subsite (right temporal bone fracture and right facial paralysis). There is one pathophysiological pattern for a single temporal bone fracture in a subsite. The authors present a bilateral isolated different pathophysiological pattern sudden onset facial paralysis in a patient herein.

Isolated Traumatic Diastasis of the Clival Synchondroses without Clival Fracture.

Traumatic clival fractures in the pediatric population are associated with high mortality rates. In our previously reported series, a subset of clival fractures were associated with traumatic diastasis of the surrounding clival synchondroses. Herein, we describe a pediatric case of an isolated traumatic diastasis of the clival synchondroses without clival fracture with significant injury to neurovascular structures. To our knowledge this is the first report to describe this entity. Careful radiological attention should be made towards the clival synchondroses in crushing head injuries to best tailor screening for cerebrovascular injury even in the absence of clival fractures.

Do blast induced skull flexures result in axonal deformation?

Subject-specific computer models (male and female) of the human head were used to investigate the possible axonal deformation resulting from the primary phase blast-induced skull flexures. The corresponding axonal tractography was explicitly incorporated into these finite element models using a recently developed technique based on the embedded finite element method. These models were subjected to extensive verification against experimental studies which examined their pressure and displacement response under a wide range of loading conditions. Once verified, a parametric study was developed to investigate the axonal deformation for a wide range of loading overpressures and directions as well as varying cerebrospinal fluid (CSF) material models. This study focuses on early times during a blast event, just as the shock transverses the skull (< 5 milliseconds). Corresponding boundary conditions were applied to eliminate the rotation effects and the resulting axonal deformation. A total of 138 simulations were developed- 128 simulations for studying the different loading scenarios and 10 simulations for studying the effects of CSF material model variance-leading to a total of 10,702 simulation core hours. Extreme strains and strain rates along each of the fiber tracts in each of these scenarios were documented and presented here. The results suggest that the blast-induced skull flexures result in strain rates as high as 150-378 s-1. These high-strain rates of the axonal fiber tracts, caused by flexural displacement of the skull, could lead to a rate dependent micro-structural axonal damage, as pointed by other researchers.

Comparison between early and delayed facial nerve decompression in traumatic facial nerve paralysis - A retrospective study.

Purpose To study the intraoperative findings in case of early and delayed decompression of facial nerve paralysis and compare their results. Methods Retrospective data analysis of 23 cases of longitudinal temporal bone fracture with House-Brackmann grade V and VI facial nerve paralysis. All cases were thoroughly evaluated and underwent facial nerve decompression through the transmastoid approach. All cases were under regular follow-up till the date of manuscript submission. Results Clinical improvement of the facial nerve function was observed for early vs. delayed facial nerve decompression. In the early decompression group, facial nerve function improved to grade II in eight cases (80%) and grade III in two cases (20%), whereas in the delayed decompression group it improved to grade II in one case (7.70%), grade III in four cases (30.76%), grade IV in seven cases (53.84%), and grade V in one case (7.70%). Conclusions Early decompression of facial nerve provides better results than delayed decompression because it enables early expansion of the nerve.

Nonsurgical Treatment for Posttraumatic Complete Facial Nerve Paralysis.

Importance: Current recommendations envisage early surgical exploration for complete facial nerve paralysis associated with temporal bone fracture and unfavorable electrophysiologic features (response to electroneuronography, <5%). However, the evidence base for such a practice is weak, with the potential for spontaneous improvement being unknown, and the expected results from alternative nonsurgical treatment also undefined. Objective: To document the results of nonsurgical treatment for posttraumatic complete facial paralysis with undisplaced temporal bone fracture and unfavorable electrophysiologic features. Design, Setting, and Participants: Prospective cohort study recruiting from April 2010 to April 2013 at a tertiary care university hospital. Follow-up continued until 9 months or until complete recovery if earlier. Study group included 28 patients with head injury-associated complete unilateral facial nerve paralysis with unfavorable results of electroneuronography (<5% response) with or without undisplaced temporal bone fracture. Undisplaced temporal bone fractures were documented in 26 patients (24 longitudinal fractures and 2 transverse fractures). Interventions: Patients received prednisolone, 1 mg/kg, for 3 weeks combined with clinical monitoring every 2 weeks and electromyography monitoring every 4 weeks. As per study protocol, surgical exploration was limited to patients demonstrating motor end plate degeneration on results of electromyography, or having no improvement until 18 weeks. Main Outcomes and Measures: Facial nerve function was evaluated by the House-Brackmann grading system; Forehead, Eye, Mouth, and Associated defect grading system; and the modified Adour system. Observations were completed at 40 weeks. Results: Among the 28 patients in the study (3 women and 25 men; mean [SD] age, 32.2 [8.7] years), facial nerve recovery with conservative treatment alone was noted in all patients. No recovery was seen in any patient at the initial 4-week review. The first signs of clinical recovery were noted in 4 patients by 8 weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks. No patient required surgical exploration. At 40 weeks, 27 patients recovered to House-Brackmann grade I/II and 1 patient to grade III. All 24 patients with longitudinal fractures had grade I/II recovery. Conclusions and Relevance: For undisplaced temporal bone fractures, nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results. Recovery is delayed and usually first manifests at 8 to 12 weeks after the fracture. In the current era of high-resolution computed tomography, surgical exploration should not be first-line treatment for undisplaced longitudingal temporal bone fractures associated with complete facial nerve paralysis and unfavorable electrophysiologic features.

Comparison between early and delayed facial nerve decompression in traumatic facial nerve paralysis - A retrospective study

ABSTRACT Purpose To study the intraoperative findings in case of early and delayed decompression of facial nerve paralysis and compare their results. Methods Retrospective data analysis of 23 cases of longitudinal temporal bone fracture with House-Brackmann grade V and VI facial nerve paralysis. All cases were thoroughly evaluated and underwent facial nerve decompression through the transmastoid approach. All cases were under regular follow-up till the date of manuscript submission. Results Clinical improvement of the facial nerve function was observed for early vs. delayed facial nerve decompression. In the early decompression group, facial nerve function improved to grade II in eight cases (80%) and grade III in two cases (20%), whereas in the delayed decompression group it improved to grade II in one case (7.70%), grade III in four cases (30.76%), grade IV in seven cases (53.84%), and grade V in one case (7.70%). Conclusions Early decompression of facial nerve provides better results than delayed decompression because it enables early expansion of the nerve.

Enhanced bone formation by strontium modified calcium sulfate hemihydrate in ovariectomized rat critical-size calvarial defects.

The development of a new generation of biomaterials with high osteogenic ability for treatment of osteoporotic fractures is being intensively investigated. The objective of this paper was to investigate new bone formation in an ovariectomized rat (OVX rat) calvarial model of critical size bone defects filled with Sr-containing α-calcium sulfate hemihydrate (SrCSH) cement compared to an α-calcium sulfate hemihydrate (α-CSH) cement and empty defect. X-ray diffraction analysis verified the partial substitution of Sr2+ for Ca2+ did not change the phase composition of α-CSH. Scanning electron microscopy showed that Sr-substituted α-CSH significantly increased the surface roughness. The effects of Sr substitution on the biological properties of SrCSH cement were evaluated by adhesion, proliferation, alkaline phosphatase (ALP) activity of osteoblast-like cells MC3T3-E1. The results showed that SrCSHs enhanced MC3T3-E1 cell proliferation, differentiation, and ALP activity. Furthermore, SrCSH cement was used to repair critical-sized OVX rat calvarial defects. The in vivo results revealed that SrCSH had good osteogenic capability and stimulated new blood vessel formation in a critical sized OVX calvarial defect within 12 weeks, suggesting that SrCSH cement has more potential for application in bone tissue regeneration.

Nasal Injuries in Sports.

Nasal trauma is a common consequence of athletic competition. The nasal bones are the most commonly fractured facial bone and are particularly at risk during sports participation. Acute management of trauma to the nose includes thorough evaluation of all injuries and may require immediate management for repair of facial lacerations, epistaxis control, or septal hematoma drainage. Nasal fractures can often be addressed with closed reduction techniques; however, in the setting of complex nasal trauma, an open approach may be indicated. Using appropriate treatment techniques, posttraumatic nasal sequelae can be minimized; most patients report satisfactory long-term nasal form and function.

Enhanced critical-size calvarial bone healing by ASCs engineered with Cre/loxP-based hybrid baculovirus.

Calvarial bone repair remains challenging for adults. Although adipose-derived stem cells (ASCs) hold promise to heal bone defects, use of ASCs for critical-size calvarial bone repair is ineffective. Stromal cell-derived factor 1 (SDF-1) is a chemokine capable of triggering stem cell migration. Although recombinant SDF-1 protein is co-delivered with other molecules including BMP-2 to facilitate calvarial bone repair, these approaches did not yield satisfactory healing. This study aimed to exploit a newly developed Cre/loxP-based hybrid baculovirus for efficient gene delivery and prolonged transgene expression in ASCs. We demonstrated that transduction of rat ASCs with the hybrid Cre/loxP-based baculovirus enabled robust and sustained expression of functional BMP-2 and SDF-1. Expression of BMP-2 or SDF-1 alone failed to effectively induce rat ASCs osteogenesis and healing of critical-size calvarial bone defects. Nonetheless, prolonged BMP-2/SDF-1 co-expression in ASCs synergistically activated both Smad and ERK1/2 pathways and hence potentiated the osteogenesis. Consequently, transplantation of the hybrid baculovirus-engineered, BMP-2/SDF-1-expressing ASCs/scaffold constructs potently healed the critical-size (6 mm) calvarial bone defects (filling ≈70% of defect volume), which considerably outperformed the calvarial bone repair using BMP-2/SDF-1 delivered with biomaterial-based scaffolds. These data implicated the potential of Cre/loxP-based hybrid baculovirus vector for ASCs engineering and calvarial bone healing.

Traumatic elevated vertex fracture with delayed increase in intracranial pressure: a rare case.

INTRODUCTION: Skull fractures are traditionally classified into linear, comminuted or depressed which can either be simple or compound. A skull fracture where the bone fragment is elevated above the intact skull known as elevated skull fracture has been reported infrequently in literature. CASE PRESENTATION: We report a unique case of simple elevated vertex fracture in a 3-month-old child where the vertex had separated from the calvarium and was elevated above the level of outer table in a patient with delayed neurological deterioration. Cerebrospinal fluid leak into tight subgaleal space and gradual thrombosis of superior sagittal sinus could have led to late clinical deterioration. CONCLUSION: Prolonged monitoring, probably early repair of dural tear and aggressive management of raised ICP, is required. Reduction of fracture with careful manipulation of SSS should weigh the risk of exsanguination. No such case of an elevated vertex fracture has been reported so far in the literature.