Sagittal craniosynostosis associated with midline cephalhematoma or vice versa, case report and a review of the literature.

INTRODUCTION: Sagittal craniosynostosis associated with midline cephalhematoma is a rare finding. Despite the controversy regarding its etiopathogenesis, this condition represents a clear indication for surgery. CASE REPORT: We present a case of a 10-week-old boy with an ossified midline vertex cephalhematoma and sagittal craniosynostosis. The child underwent a cephalhematoma excision and minimally invasive non-endoscopic narrow vertex craniectomy, with calvarial vault remodeling followed by 2 weeks use of a cranial orthosis. On 5-month follow-up, mesocephaly was achieved. CONCLUSION: Our case is well documented with native CT, 3D CT, intraoperative pictures, and 3D head scan imaging. We described our minimally invasive non-endoscopic technique that led to a rapid cranial vault remodeling with reduction of cranial orthosis need. A review of literature focused on surgical techniques is included.

Newborn with a depression to her skull.

A 9 week-old female, born via normal spontaneous vaginal delivery at 40 weeks, presented to the emergency department for a depression to her left skull, first noticed 3 three weeks prior. Ping Pong Fractures should be recognized and appropriately treated by an emergency physician.

Intradiploic hematoma in an infant: case report and literature review.

Intradiploic hematoma is extremely rare, especially in infant patients. Less than 15 cases were reported in English literature up to now. Here, we presented another intradiploic hematoma in an infant boy without coagulopathy. A left parietal craniotomy was performed. Post-operative CT showed well-reconstructed skull.

Craniocerebral birth injuries in term newborn infants: a retrospective series.

OBJECTIVE: In an attempt to further define the spectrum of cranial birth injuries, we analyzed 21 consecutive cranial birth injuries in term neonates presenting to the neurosurgical department of our institution over the period 1994-2015. METHODS: We performed a retrospective chart review from the medical records of the University Hospitals of the KU Leuven, from 1994 to 2015. We included 21 infants of 36-week gestational age or older with a diagnosis of cranial birth injury. The types and locations of injuries, the presenting signs, symptoms and their timing, and the required treatment(s) were recorded. Various maternal and neonatal factors and the mode of delivery were recorded. We recorded the different modes of delivery rates at our institution in the year 2013 and the rates in the Flemish community between 1995 and 2013, in order to compare the mode of delivery rates in the study group with current practice at our institution and with general practice over the years in the Flemish community. RESULTS: The most common clinical presentations were swelling (43% of cases) and seizures (19% of cases). Average Apgar scores were 6.57 at 1 min and 8.43 at 5 min; 48% of children had abnormally low Apgar scores at 1 min and 9.5% had abnormally low scores at 5 min. The most common intracranial lesion was skull fractures (33%). Operative treatment was required in 11 infants (52%). One infant died. Assisted mechanical delivery by either forceps and/or vacuum extraction occurred in 43% of infants. In comparison, in the year 2013, only 13.97% of deliveries at our institution were mechanically assisted. Over the period 1995-2013, the highest mechanically assisted delivery rates in the Flemish community were 14.1% in 1996. CONCLUSION: Although our series is too small to make firm conclusions, it is remarkable that the rates of assisted mechanical deliveries in our series far exceeded the assisted mechanical delivery rates at our institution in the year 2013 and even the highest vacuum and forceps delivery rates in the Flemish community over the period 1995-2013.

The role of muscle imbalance in the pathogenesis of shoulder contracture after neonatal brachial plexus palsy: a study in a rat model.

BACKGROUND: An internal rotation contracture of the shoulder is common after neonatal brachial plexus injuries due to subscapularis shortening and atrophy. It has been explained by 2 theories: muscle denervation and muscle imbalance between the internal and external rotators of the shoulder. The goal of this study was to test the hypothesis that muscle imbalance alone could cause subscapularis changes and shoulder contracture. MATERIALS AND METHODS: We performed selective neurectomy of the suprascapular nerve in 15 newborn rats to denervate only the supraspinatus and the infraspinatus muscles, leaving the subscapularis muscle intact. After 4 weeks, passive shoulder external rotation was measured and a 7.2-T magnetic resonance imaging scan of the shoulders was used to determine changes in the infraspinatus and subscapularis muscles. The subscapularis muscle was weighed to determine the degree of mass loss. An additional group of 10 newborn rats was evaluated to determine the sectional muscle fiber size and muscle area of fibrosis by use of images from type I collagen immunostaining. RESULTS: There was a significant decrease in passive shoulder external rotation, with a mean loss of 66°; in the thickness of the denervated infraspinatus, with a mean loss of 40%; and in the thickness and weight of the non-denervated subscapularis, with mean losses of 28% and 25%, respectively. No differences were found in subscapularis muscle fiber size and area of fibrosis between shoulders after suprascapular nerve injury. CONCLUSIONS: Our study supports the theory that shoulder muscle imbalance is a cause of shoulder contracture in patients with neonatal brachial plexus palsy.

Geometry of the proximal humeral articular surface in young children: a study to define normal and analyze the dysplasia due to brachial plexus birth palsy.

BACKGROUND: Little is known regarding the morphology of the proximal humerus in growing children. This study reports bilateral magnetic resonance imaging measurements in children with internal rotation contractures from birth palsy, hypothesizing that dysplasia alters normal humeral sphericity and symmetry. METHODS: We studied 25 children with unilateral internal rotation contractures (mean age, 3.7 years) for humeral shape by bilateral magnetic resonance imaging studies at the mid-glenoid level. Local radii of curvature were compared for symmetry and orientation. RESULTS: Neither side showed uniform radii (sphericity), but normal humeri showed symmetry lost in dysplasia. Internal rotation contractures were correlated with flattening of the anterior humeral head (P = .0002). All heads were flatter in the region of articular contact. The skew axis (the largest cross-sectional diameter of the proximal humerus) was collinear with the articular surface centerline in normal humeri, an alignment often lost with dysplasia, resulting in a skew axis angle. The severity of glenoid deformity correlated with progressive posterior displacement of the humeral head center (P < .0003). CONCLUSION: The normal humeral articular surface in the young child is not spherical and is flatter in the middle than at the periphery but is symmetric about its central axis. Internal rotation contractures result in loss of this symmetry with characteristic flattening of the anterior humeral head and development of a skew axis angle. CLINICAL RELEVANCE: Posterior displacement of the humeral head center of rotation beyond 50% of the calculated head radius warrants vigilance and possibly surgical intervention because there is a high likelihood for development of a pseudoglenoid.

Caput succedaneum and facial petechiae--birth-associated injuries in healthy newborns under forensic aspects.

In cases of suspected neonaticide, the results of a forensic autopsy might be important for conviction or acquittal. But autopsy findings in dead newborns are often unspecific and can rarely provide corroborative evidence of inflicted injury, as they are known to occur during normal birth as well. In our study, we examined 59 vaginally delivered, healthy newborns within the first 30 min after birth to know more about the prevalence and possible correlations of a caput succedaneum and facial petechiae. Caput succedaneum occurred in 33.9%, facial petechiae in 20.3%. As for the occurrence of caput succedaneum, statistically significant differences could be shown for the duration of delivery and the mother's parity. These correlations could not be shown for the occurrence of facial petechiae. Within the scope of our study, we could demonstrate that neither caput succedaneum nor facial petechiae are rare findings in healthy newborns. In the forensic investigation of suspected neonaticide, their potential significance can only be ascertained together with further investigations of the circumstances of death and a thorough forensic pathological autopsy.

[Age-related dynamics of structure changes in the 17th cortical area of children with perinatal affection of the nervous system].

Brain autopsy of children standing afterperinatal affection of the nervous system and healthy children without any neurological disorders (a control group) has been studied by computers morphometric methods. The age-related dynamics of structure parameters in the 17th cortical area was investigated. Correlation between increasing of cortical lamina's diameters and age of children with perinatal affection of the brain wasn't revealed. The width of IVand V cortical layers, size of neurons and their density in the cortex of children with perinatal pathology were significantly fewer than in the control group. However the density of glia including GFAP-positive astroglia in the children with prenatal pathology was higher to compare with the control group. We suggest that detected disorders are signs of nonspecific structure-functional changes in the visual cortex and follows destructive and compensatory restorative reactions.

Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience.

BACKGROUND: Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years. METHODS: All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort. RESULTS: Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications. CONCLUSIONS: This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Magnetic resonance imaging and clinical findings before and after tendon transfers about the shoulder in children with residual brachial plexus birth palsy: a 3-year follow-up study.

BACKGROUND: Incomplete recovery after brachial plexus birth palsy often results in decreased movement and muscle imbalance about the shoulder, as rotator cuff and deltoid innervation are incomplete. Tendon transfers redistribute the forces about the joint and were thought to promote glenohumeral joint remodeling. Early reports, however, indicate limited ability to affect joint configuration. Our previous report and conclusions to this regard were based upon short follow-up. The purpose of this study was to assess the magnetic resonance imaging and clinical outcome after tendon transfers about the shoulder in children with residual brachial plexus birth palsy. METHODS: This was a retrospective chart review of 24 children who underwent transfer of the latissimus dorsi and teres major to the posterior rotator cuff with or without concomitant musculotendinous lengthenings. Follow-up magnetic resonance imaging data were available for all subjects at 1-year postsurgery and 19 subjects at 3-year follow-up. RESULTS: Preoperative average glenoid version was -25+/-13 degrees (range, -51- -11 degrees). Compared with preoperative version, there was no statistical difference at 1 year (-25+/-14 degrees; range, -56- -7 degrees; P=1.00) or at 3 years (-22+/-11 degrees; range, -54- -8 degrees; P=1.00). Preoperative average percent of humeral head anterior was 29%+/-15% (range, 0%-44%). Compared with preoperative percent of humeral head anterior, there was no statistical difference at 1 year (28%+/-16%; range, 0%-52%; P=1.00) or at 3 years (35%+/-13%; range, 0%-51%; P=0.32). Clinical evaluation showed significant improvements (P<0.05) in preoperative (-3+/-21) to 1-year (18+/-32) external rotation Significant improvements in abduction were found from 116+/-39 degrees before surgery to 151+/-30 degrees and 161+/-20 degrees at 1 and 3 years after surgery, respectively. CONCLUSIONS: These results demonstrate that tendon transfers improve overall shoulder motion, but do not reduce humeral head subluxation or improve glenohumeral joint realignment. LEVEL OF EVIDENCE: Level IV.

Calving-related intradural avulsion injuries of the thoracolumbar spinal nerve roots in a calf.

Calving difficulty may lead to traumatic peripheral nerve injury. A male, 8-mo-old, Japanese Black calf with a history of secondary dystocia as a result of fetal gigantism had lameness and gait disturbance. At autopsy, multifocal dural thickening with adhesions to the adjacent spinal cord was observed at T12-13 and L4-5 vertebral levels. Microscopically, numerous traumatic neuroma-like fascicles of nerve twigs were embedded in the dura mater with abundant collagenous connective tissue. By immunohistochemistry, axons and Schwann cells were confirmed in each nerve fascicle. Our observations suggest that avulsion injuries in the preganglionic fibers of the spinal nerve roots, and secondary spinal cord compression, resulted in the development of neurologic signs.

Severe shoulder dystocia leading to neonatal injury: a case control study.

BACKGROUND AND OBJECTIVES: Severe shoulder dystocia (SD) is associated with neonatal brachial plexus injuries and skeletal fractures, with the former being the commonest cause for litigation related to birth trauma. The aim of this case-control study was to evaluate risk factors for birth injuries in cases presenting with SD. METHODS: Between January 2000 and December 2006, 22 babies who sustained brachial nerve paralysis or skeletal fractures following severe SD and requiring admission to Special Care Baby Unit (SCBU) were identified. The control group (n = 22) comprised the next infant delivered who was deemed to have SD but did not suffer significant birth injuries. Antenatal, labour and postnatal data were collected and compared between the two groups. RESULTS: The study and control groups had similar median maternal age (28 vs. 26.5 years), gestational age at delivery (40 vs. 40 weeks) and estimated blood loss (300 vs. 225 ml) (both P > 0.05, Mann-Whitney test). Median 1 min Apgar scores (5.5 vs. 7), maternal BMI (31.34 vs. 27.19 kg/m(2)) and duration of second stages (53.8 vs. 49.2 min) were also statistically similar in both groups (P > 0.05). However, compared to controls, brachial nerve injuries and skeletal fractures were more likely to occur in mothers with gestational diabetes (5/22 vs. 1/22) or who had previous big babies (4/22 vs. 1/22) (both P < 0.05, Fisher's exact test). Babies who had birth injuries were also more likely to have greater median birth weights (4.3 vs. 3.8 kg) and postnatal anthropometric measurements such as head circumference (35 vs. 34 cm) and ponderal indices (81.9 vs. 74.3 kg/m(3)) compared to controls. CONCLUSION: In babies with SD, brachial nerve injuries and skeletal fractures are more likely to occur in those with greater birthweights but also larger length to weight ratios. In these babies, assessment of abdominal circumference and biacromial length by magnetic resonance imaging (MRI) may help predict the likelihood of severe SD, especially in mothers with identifiable risk factors. However, further research in larger controlled trials are still needed to determine their predictive value.

Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery.

INTRODUCTION: Bilateral femoral fracture due to birth trauma which is extremely rare, can occur during cesarean section. MATERIAL AND METHODS: This case represents a newborn delivered by cesarean section for breech presentation who sustained bilateral subtrochanteric fracture of the femur. RESULT: The newborn was treated with immobilization in pelvipedal cast. CONCLUSION: It has been concluded that performing accurate delivery technique and immediate evaluation-orthopedic consultation of the newborn in the presence of forced obstetrical maneuver are important.

Computational analysis of glenohumeral joint growth and morphology following a brachial plexus birth injury.

Children affected with brachial plexus birth injury (BPBI) undergo muscle paralysis. About 33% of affected children experience permanent osseous deformities of the glenohumeral joint. Recent evidence suggests that some cases experience restricted muscle longitudinal growth in addition to paralysis and reduced range of motion at the shoulder and elbow. It is unknown whether altered loading due to paralysis, muscle growth restriction and contracture, or static loading due to disuse is the primary driver of joint deformity after BPBI. This study uses a computational framework integrating finite element analysis and musculoskeletal modeling to examine the mechanical factors contributing to changes in bone growth and morphometry following BPBI. Simulations of 8 weeks of glenohumeral growth in a rat model of BPBI predicted that static loading of the joint is primarily responsible for joint deformation consistent with experimental measures of bone morphology, whereas dynamic loads resulted in normal bone growth. Under dynamic loading, glenoid version angle (GVA), glenoid inclination angle (GIA), and glenoid radius of curvature (GRC) (-1.3°, 38.2°, 2.5 mm respectively) were similar to the baseline values (-1.8°, -38°, 2.1 mm respectively). In the static case with unrestricted muscle growth, these measures increased in magnitude (5.2°, -48°, 3.5 mm respectively). More severe joint deformations were observed in GIA and GRC when muscle growth was restricted (GVA: 3.6°, GIA: -55°, GRC: 4.0 mm). Predicted morphology was consistent with literature reports of in vivo glenoid morphology following postganglionic BPBI. This growth model provides a framework for understanding the most influential mechanical factors driving glenohumeral deformity following BPBI.

Birth injury of the cranium and central nervous system.

Birth injury of the scalp, skull and central nervous system (CNS) is a well-recognized complication of a difficult delivery. The rate of birth trauma has dropped precipitously and now accounts for less than 2% of neonatal deaths. Despite this dramatic decrease in birth-trauma mortality significant injuries still occur. A variety of risk factors clearly predispose certain infants to birth-related injury. Recent neuroradiology studies indicate that intracranial hemorrhage, even in asymptomatic infants, is not rare. Pathologists' (neuropathologists and forensic pathologists) appreciation of the spectrum of birth injuries and their sequelae is critical in order to be able to distinguish these from inflicted injuries and post-mortem changes.

Sub-aponeurotic fluid collections: a delayed-onset self-limiting cerebrospinal fluid fistula in young infants.

BACKGROUND: Transient sub-aponeurotic fluid collections are rarely recognized lesions that may be frequently related to traumatic labor and occur within weeks after birth. Their etiology has remained uncertain. METHODS AND RESULTS: Here we report on five new cases with typical clinical findings and normal neuroimaging. A detailed analysis of the lesion aspirates was performed in three patients, always revealing beta(2)-transferrin and high concentrations of beta-trace protein. CONCLUSIONS: This indicates that cerebrospinal fluid leakage contributes to this rare condition. All lesions disappeared spontaneously within 2-5 months so that conservative treatment seems appropriate.

Parasagittal lesions and ulegyria in hypoxic-ischemic encephalopathy: neuroimaging findings and review of the pathogenesis.

Hypoxic-ischemic brain injury is a very important neurological problem of the perinatal period and a major cause of chronic disability later in childhood. The subsequent neurological deficits are a variety of motor defects-especially spasticity but also choreoathetosis, dystonia and ataxia, often grouped together as "cerebral palsy," mental retardation, and seizures. The gestational age determines the neuropathology of the brain injury. One of the patterns of hypoxic-ischemic encephalopathy, typically affecting full-term infants, consists of parasagittal lesions and ulegyria. The aim of this study is to describe the magnetic resonance imaging (MRI) features and discuss the "suggested" pathogenetic mechanisms of this pattern, which affects the cortex and the white matter in a mainly parasagittal distribution; in this type of brain injury, the damage usually involves the deeper sulcal portion while sparing the apex, thus resulting in the so-called mushroom gyri characteristic ulegyric pattern. We discuss the MRI findings of parasagittal lesions and ulegyria in the brain examinations of 14 patients with a clinical history of perinatal hypoxia/anoxia presenting with mental retardation, seizures, and cerebral palsy. Differential diagnosis from polymicrogyria is discussed.

[Self-deliverance or infanticide?]. / Selbsthilfe bei der Geburt oder Tötung des Neugeborenen?

Self-deliverance by a woman in labour is nowadays a very rare event. The authors report the case of a 24-year-old primipara and a newborn of 49 cm length and 2484 g body weight with a complex pattern of injuries on the head, neck, shoulder and back who had breathed for at least 15 to 30 minutes after birth and died from massive craniocerebral trauma and lesions in the oral and cervical region. As one of the experts considered it possible that the skull fractures were exclusively due to the self-deliverance, the woman was acquitted of the charge of manslaughter. This hypothesis is critically discussed on the basis of the presumable course of the delivery and the literature.

[Anatomic approach to the sphenooccipital synchondrosis in newborns and infants with craniocerebral injury].

An anatomic approach is developed to sphenooccipital synchondrosis in newborn infants and nurslings. After removal of the squamous portion of the occipital bone by the method of Medvedev, opening of the cerebrospinal canal, removal of the spinal cord and hypophysis, two parallel cuts converging at an angle of approximately 90 degrees were made with a dissecting blade saw along both sides of sella turcica towards the anterior edge of the great occipital foramen to transect the sphenoid bone and main part of the occipital bone. The resulting osteochondrous fragment showed up defects in synchondrosis including consolidated ones.