The Incidence of Depressed Skull Fractures Due to the Use of Pin-Type Head Frame Systems in the Adult Population: 10-year Experience of a Single Neurosurgical Center.

OBJECTIVE: Pin-type head frame systems have become a worldwide standard procedure, but they can cause some complications on rare occasions. This study aimed to examine the incidence and associated risk factors of depressed skull fracture and related intracranial hematoma (DSFH) due to the use of head frames in our institute over the past 10 years. METHODS: This study included 1749 patients who underwent neurosurgical surgeries using pin-type head frames, including the Mayfield (Integra NeuroSciences, Plainsboro, NJ) skull clamp (721 cases) and the Sugita (Mizuho Ikakogyo Co., Ltd., Tokyo, Japan) head frame (1028 cases). We retrospectively reviewed hospital records of our institute to identify cases of DSFH, and documented the type of head frame used, as well as patient characteristics. RESULTS: The incidence of DSFH was 0.29% (5 of 1749 cases). All 5 cases had an associated epidural hematoma, with a single case having an additional dural laceration (without subdural damage). All perforation sites, located at the parietal bone near the pterion, occurred by the unilateral horizontal screw of the Sugita head frame. None of the patients experienced postoperative neurological decline. CONCLUSIONS: Even in the adult population, the DSFH by the pin-type head frame can occur infrequently. Based on our results, we recommend that the following factors should be considered when the pin-type head frame is used for neurosurgical procedures: location of pin application, thickness and fragility of the skull, and adequate control of compressive forces exerted by the head frame.

Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study.

STUDY OBJECTIVE: Existing clinical decision rules guide management for head-injured children presenting 24 hours or sooner after injury, even though some may present greater than 24 hours afterward. We seek to determine the prevalence of traumatic brain injuries for patients presenting to emergency departments greater than 24 hours after injury and identify symptoms and signs to guide management. METHODS: This was a planned secondary analysis of the Australasian Paediatric Head Injury Rule Study, concentrating on first presentations greater than 24 hours after injury, with Glasgow Coma Scale scores 14 and 15. We sought associations with predictors of traumatic brain injury on computed tomography (CT) and clinically important traumatic brain injury. RESULTS: Of 19,765 eligible children, 981 (5.0%) presented greater than 24 hours after injury, and 465 injuries (48.5%) resulted from falls less than 1 m and 37 (3.8%) involved traffic incidents. Features associated significantly with presenting greater than 24 hours after injury in comparison with presenting within 24 hours were nonfrontal scalp hematoma (20.8% versus 18.1%), headache (31.6% versus 19.9%), vomiting (30.0% versus 16.3%), and assault with nonaccidental injury concerns (1.4% versus 0.4%). Traumatic brain injury on CT occurred in 37 patients (3.8%), including suspicion of depressed skull fracture (8 [0.8%]) and intracranial hemorrhage (31 [3.8%]). Clinically important traumatic brain injury occurred in 8 patients (0.8%), with 2 (0.2%) requiring neurosurgery, with no deaths. Suspicion of depressed skull fracture was associated with traumatic brain injury on CT consistently, with the only other significant factor being nonfrontal scalp hematoma (odds ratio 19.0; 95% confidence interval 8.2 to 43.9). Clinically important traumatic brain injury was also associated with nonfrontal scalp hematoma (odds ratio 11.7; 95% confidence interval 2.4 to 58.6) and suspicion of depressed fracture (odds ratio 19.7; 95% confidence interval 2.1 to 182.1). CONCLUSION: Delayed presentation after head injury, although infrequent, is significantly associated with traumatic brain injury. Evaluation of delayed presentations must consider identified factors associated with this increased risk.

Reappraisal of Neonatal Greenstick Skull Fractures Caused by Birth Injuries: Comparison of 3-Dimensional Reconstructed Computed Tomography and Simple Skull Radiographs.

OBJECTIVE: The most common birth-associated head injuries during vaginal delivery are cephalhematomas and subgaleal hematomas. Cranial injuries are rarely encountered. The neonate cranium is soft and pliable, and greenstick skull fractures (GSFs) are expected to be more frequent than linear or depressed fractures, but they are extremely difficult to detect with simple skull radiography. As a result, no reports have been issued on this topic to date. Recent reports suggest that technological advances in 3-dimensional (3D) computed tomography (CT) have successfully enhanced the diagnostic accuracy for cranial fractures. The authors researched the types and characteristics of GSFs and the diagnostic accuracy of 3D CT for cranial fractures in neonates. METHODS: The simple skull radiographs and 3D CT images of 101 neonates were retrospectively evaluated and compared with respect to diagnosis of cranial fractures, and skull GSFs were classified on the basis of 3D CT findings into 5 types depending on multiplicity and location. RESULTS: 3D CT detected 88 cases of cranial fractures, that is, 89 GSFs, 4 combined GSFs and linear fractures, and 3 combined GSFs and depressed fractures. The diagnostic rate of 3DCT was 91% and this was significantly higher than the 13% rate of simple skull radiographs (P < 0.001). CONCLUSIONS: GSFs rather than linear fractures were found to account for most cranial injuries among neonates. The diagnostic accuracy of 3D CT was considerably superior than simple skull radiography, but the high radiation exposure levels of 3D CT warrant the need for development of a modality with lower radiation exposure.

[Pediatric head injuries, retrospective analysis of 851 patients: an epidemiological study]. / Çocukluk çagi kafa travmalari, 851 olgunun retrospektif degerlendirilmesi: Epidemiyolojik bir çalisma.

BACKGROUND: The aim of this study was to contribute to the epidemiological database of our country about pediatric head injuries. METHODS: We retrospectively analyzed 851 patients younger than 14 years old with head injury, treated in the Neurosurgery Department of Samsun Mehmet Aydin Education and Research Hospital between January 2003 and June 2008. RESULTS: Five hundred and fifty (65%) patients were male and 301 (35%) were female. Falls (70%) were the most common cause of head injury. According to Glasgow Coma Score (GCS), 74% of patients had mild (13-15), 22% moderate (9-12) and 4% severe (3-8) head injury. Eighty-seven (10.5%) patients were operated. The commonest operations were performed for depressed fractures and epidural hematomas. The mortality rate was 3.8% (33). Common causes of mortality were traffic accidents and falls from heights. CONCLUSION: Other reported studies and this study show that the majority of pediatric head injuries occur as a result of preventable causes. It is important to have local epidemiological studies and data about head injuries in order to prevent these traumas before their occurrence.

Five years' experience at a single centre of craniocerebral injury from winnowing fan blades.

India, an agriculture-based country, relies heavily on indigenous farm machinery. In our study we present 31 patients with winnowing fan blade head injury, operated on at our centre between 2004 and 2008. The mechanism and nature of the injuries, operative methods, outcome and methods of prevention are discussed with special reference to the occurrence of this type of injury in the pediatric population.

Open depressed and penetrating skull fractures in Port Moresby General Hospital from 2003 to 2005.

BACKGROUND: Open wounds to the head with skull bone depression pose the potential for serious injuries to the brain parenchyma and an increased risk of infection. The treatment of these injuries aims to repair the breached dura as well as remove any nidus for infection. Open wounds to the head due to bullets pose special problems and have a high fatality rate. AIM: To review the presentation, management and outcome of depressed and penetrating open fractures of the skull in Port Moresby. METHOD: All cases seen from 2003 to 2005 were included. All were managed without a CT (computed tomography) scan. Their Glasgow Outcome Scale (GOS) was documented on discharge. RESULTS: There were 340 traumatic brain injury (TBI) cases over a period of 3 years between 2003 and 2005 managed by the Neurosurgery Unit of Port Moresby General Hospital. The open depressed and penetrating skull fractures seen in these cases numbered 46 (14%), of which 42 were males and 4 females. The weapons most commonly used were blunt objects (16), knives (11), guns (6) and axes (4). Gunshots contributed to 4 of the 7 deaths. 4 out of the 7 deaths were due to primary brain injury and 3 were due to infection. CONCLUSION: Open depressed fractures and penetrating injuries form a small but significant group in the management of head injuries. The use of blunt objects, firearms and arrows coupled with increasing urban violence is responsible for most of these injuries. The outcome of patients admitted who are fully conscious is expected to be good. They can be managed by prompt debridement of the wound, elevation of the fracture and removal of fragments as appropriate. However, the mortality rate is high in those with a Glasgow Coma Score of 8 or less on admission, a finding indicative of the severity of brain injury beneath the wound.

Golf-associated head injury in the pediatric population: a common sports injury.

OBJECT: Golf-related injuries constitute a common type of sports injury in the pediatric population. The increase in the frequency of these injuries is largely attributed to the increase in the popularity of golf and greater use of golf carts by children. METHODS: The purpose of this study was to investigate the mechanisms and complications associated with golf-related injuries in the pediatric population and, by doing so, assist in the prevention of such injuries. We reviewed the charts of 2546 pediatric patients evaluated by the neurosurgery service at the authors' institution over a 6-year period. There were 64 cases of sports-related injuries. Of these, 15 (23%) were golf-related, making these injuries the second-largest group of sports-related injuries. Depressed skull fracture was the most common injury observed. Neurosurgical intervention was required in 33% of the cases. With rare exceptions, patients made good recoveries during a mean follow-up period of 22.2 months. One death occurred due to uncontrollable cerebral edema following a golf cart accident. One child required shunt placement and several revisions following an injury sustained from a golf ball. CONCLUSIONS: Children should be advised on the proper use of golf equipment as a preventive measure to avoid these injuries. Precautionary guidelines and safety training guidelines should be established. The institution of a legal minimum age required to operate a golf cart should be considered.

Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates.

OBJECTIVE: A depressed skull fracture is an inward buckling of the calvarial bones and is referred to as a "ping-pong" fracture. This study aimed to look at differences between "spontaneous" and "instrument-associated" depressed skull fractures. STUDY DESIGN: This retrospective, case-control analysis included every neonate who was admitted with a depressed skull fracture between 1990 and 2000. Cases after a spontaneous vaginal delivery, elective cesarean delivery, or cesarean delivery that was performed during labor without previous instrument use were classified as "spontaneous" (n = 18 cases). Cases after a delivery in which forceps or a vacuum cup had been used either successfully or unsuccessfully were classified as "instrument-associated" (n = 50 cases). Continuous data were analyzed with 2-tailed unpaired t tests; chi 2 analysis was used for nominal data. A probability value of <.05 was considered statistically significant. RESULTS: Fifty depressed skull fractures were associated with an instrument delivery, and 18 depressed skull fractures were classified as "spontaneous." The only obstetric parameter that differed significantly between the 2 groups was the length of the active phase. Among the 68 neonates, 15 neonates underwent prolonged second stage, forceps or manual head rotation, or forceps use during elective cesarean delivery. All "instrument-associated" cases were caused by forceps application or sequential instrument use; depressed skull fractures never occurred after isolated vacuum extraction. Every type of forceps was involved. Intracranial lesions were significantly more frequent in the instrument-associated group (30% vs 0%; P = .02). Two infants sustained persistent severe motor disabilities. CONCLUSION: Depressed skull fractures occur in the setting of spontaneous and operative deliveries, although the incidence is higher in the latter case. Depressed skull fractures that are associated with instrumental deliveries are significantly more likely to be associated with intracranial lesions. Persistent disabilities are rare.

Blunt pediatric head trauma requiring neurosurgical intervention: how subtle can it be?

Recent literature on pediatric head injuries has suggested that important intracranial injuries might present to the ED without typical signs or symptoms. The objective of our study was to review our institutional experience with head-injured infants and young children to assess the subtlety of the ED presentation. We performed a retrospective medical record review of head-injured children