Skull fracture during instrumental delivery using spatulas: A case report with CT-scan imaging.

Neonatal skull fracture is rare and instrumental delivery is one of the risk factors. We present a case of parietal bone fracture in a term newborn with Thierry's spatulas who benefited from a 3D brain scan. If many cases have been reported with the use of forceps whatever their type, our case is to our knowledge the first one described with spatulas.

Vacuum-assisted elevation of pediatric ping-pong skull fractures: a case series and technical note.

OBJECTIVE: The management of children with ping-pong skull fractures may include observation, nonsurgical treatments, or surgical intervention depending on the age, clinical presentation, imaging findings, and cosmetic appearance of the patient. There have been 16 publications on nonsurgical treatment using negative pressure with various devices. Herein, the authors report their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate the variables affecting procedural outcomes. METHODS: The authors performed a retrospective chart review of all ping-pong skull fractures treated via vacuum-assisted elevation at the Children's Hospital of Wisconsin between 2013 and 2017. Data collected included patient age, head circumference, mode of injury, time to presentation, imaging findings, procedural details, treatment outcomes, and complications. RESULTS: Four neonates and 5 infants underwent vacuum-assisted elevation of moderate to severe ping-pong skull fractures during the study period. Modes of injury included birth-related trauma, falls, and blunt trauma. All patients had normal neurological examination findings and no evidence of intracranial hemorrhage. All fractures were deemed severe enough to require elevation by the treating neurosurgeon. All fractures involved the parietal bone. Skull depressions ranged from 23 to 62 mm in diameter and from 4 to 14 mm in depth. Bone thickness ranged from 0.6 to 1.8 mm. The time from fracture to intervention ranged from 7 hours to 8 days. The Kiwi OmniCup vacuum delivery system was used in all cases. Negative pressures were increased sequentially to a maximum of 500 mm Hg. A greater number of sequential vacuum applications was required for patients with a skull thickness greater than 1 mm at the site of depression and for those undergoing treatment more than 72 hours from fracture onset. Successful fracture elevation was attained in 7 of 9 patients. Two patients required subsequent surgical elevation of their fractures. Postprocedure imaging studies revealed no evidence of complications. CONCLUSIONS: Increasing bone thickness and time from fracture onset to intervention appeared to be the greatest limiting factors to the successful elevation of moderate to severe ping-pong fractures via this vacuum-assisted approach. This procedure is a well-tolerated option that should be considered prior to performing an open repair in cases deemed to require fracture elevation. Future efforts will focus on larger-volume studies to better delineate inclusion and exclusion criteria, and volumetric analysis for better fracture-to-suction device customization.

[Visual impairment following a suicide attempt with a crossbow]. / 'Ziende blind' na een suïcidepoging met kruisboog.

BACKGROUND: Bálint's syndrome is characterized by the triad of ocular apraxia, dorsal simultanagnosia and optic ataxia. It most commonly occurs following bilateral parieto-occipital brain injury, for which several aetiologies have been described. CASE DESCRIPTION: We present a case of a 39-year-old male with penetrating brain injury following a suicide attempt with a crossbow. A CT scan of the head revealed the intracranial position of the arrow, piercing the parietal and occipital cortex from the left-parietal direction with the tip on the right parietal bone. After surgical removal of the arrow, visuospatial symptoms persisted that were consistent with Bálint's syndrome. The characteristic symptoms, patho-anatomy and treatment of this syndrome are discussed in this article. CONCLUSION: The patient in this case had visual impairment following a suicide attempt with a crossbow. On the basis of neurological and neuropsychological assessments, the triad of ocular apraxia, dorsal simultanagnosia and optic ataxia was observed, characteristic of Bálint's syndrome.

Stress and strain propagation on infant skull from impact loads during falls: a finite element analysis.

Background and Objective: To simulate infant skull trauma after low height falls when variable degrees of ossification of the sutures are present. Methods: A finite elements model of a four-week-old infant skull was developed for simulating low height impact from 30 cm and 50 cm falls. Two impacts were simulated: An occipito-parietal impact on the lambdoid suture and a lateral impact on the right parietal and six cases were considered: unossified and fully ossified sutures, and sagittal, metopic, right lambdoid and right coronal craniosynostosis. Results: 26 simulations were performed. Results showed a marked increase in strain magnitudes in skulls with unossified sutures and fontanels. Higher deformations and lower Von Mises stress in the brain were found in occipital impacts. Fully ossified skulls showed less overall deformation and lower Von Mises stress in the brain. Results suggest that neonate skull impact when falling backward has a higher probability of resulting in permanent damage. Conclusion: This work shows an initial approximation to the mechanisms underlying TBI in neonates when exposed to low height falls common in household environments, and could be used as a starting point in the design and development of cranial orthoses and protective devices for preventing or mitigating TBI.

CRISPRai for simultaneous gene activation and inhibition to promote stem cell chondrogenesis and calvarial bone regeneration.

Calvarial bone healing remains difficult but may be improved by stimulating chondrogenesis of implanted stem cells. To simultaneously promote chondrogenesis and repress adipogenesis of stem cells, we built a CRISPRai system that comprised inactive Cas9 (dCas9), two fusion proteins as activation/repression complexes and two single guide RNA (sgRNA) as scaffolds for recruiting activator (sgRNAa) or inhibitor (sgRNAi). By plasmid transfection and co-expression in CHO cells, we validated that dCas9 coordinated with sgRNAa to recruit the activator for mCherry activation and also orchestrated with sgRNAi to recruit the repressor for d2EGFP inhibition, without cross interference. After changing the sgRNA sequence to target endogenous Sox9/PPAR-γ, we packaged the entire CRISPRai system into an all-in-one baculovirus for efficient delivery into rat bone marrow-derived mesenchymal stem cells (rBMSC) and verified simultaneous Sox9 activation and PPAR-γ repression. The activation/inhibition effects were further enhanced/prolonged by using the Cre/loxP-based hybrid baculovirus. The CRISPRai system delivered by the hybrid baculovirus stimulated chondrogenesis and repressed adipogenesis of rBMSC in 2D culture and promoted the formation of engineered cartilage in 3D culture. Importantly, implantation of the rBMSC engineered by the CRISPRai improved calvarial bone healing. This study paves a new avenue to translate the CRISPRai technology to regenerative medicine.

The infant with bilateral skull fractures: diagnostic considerations in consultation with a child abuse pediatrician.

Bilateral skull fractures in infancy may result from accidental or abusive injury. Consultation with a child abuse pediatrician may assist with determining the likelihood of accident or abuse. Diagnostic considerations for the infant with bilateral skull fractures are reviewed, including single impact, double impact, and compression mechanisms of injury, as well as the possibility of accessory sutures as skull fracture mimics. Illustrative cases exemplify the evaluative process, including obtaining a detailed history, assessing for the presence or absence of additional physical or radiographic signs of injury, screening for psychosoical risk, and obtaining three-dimensional reconstruction of CT bone images. An understanding of plausible mechanisms of injury that can result in bilateral skull fractures in infancy can assist with making an accurate determination of likelihood of accident or abuse.

Evaluating the bioactivity of a hydroxyapatite-incorporated polyetheretherketone biocomposite.

BACKGROUND: Polyetheretherketone (PEEK) exhibits stable chemical properties, excellent biocompatibility, and rational mechanical properties that are similar to those of human cortical bone, but the lack of bioactivity impedes its clinical application. METHODS: In this study, hydroxyapatite (HA) was incorporated into PEEK to fabricate HA/PEEK biocomposite using a compounding and injection-molding technique. The tensile properties of the prepared HA/PEEK composites (HA content from 0 to 40 wt%) were tested to choose an optimal HA content. To evaluate the bioactivity of the composite, the cell attachment, proliferation, spreading and alkaline phosphatase (ALP) activity of MC3T3-E1 cells, and apatite formation after immersion in simulated body fluid (SBF), and osseointegration in a rabbit cranial defect model were investigated. The results were compared to those from ultra-high molecular weight polyethylene (UHMWPE) and pure PEEK. RESULTS: By evaluating the tensile properties and elastic moduli of PEEK composite samples/PEEK composites with different HA contents, the 30 wt% HA/PEEK composite was chosen for use in the subsequent tests. The results of the cell tests demonstrated that PEEK composite samples/PEEK composite exhibited better cell attachment, proliferation, spreading, and higher ALP activity than those of UHMWPE and pure PEEK. Apatite islands formed on the HA/PEEK composite after immersion in SBF for 7 days and grew continuously with longer time periods. Animal tests indicated that bone contact and new bone formation around the HA/PEEK composite were more obvious than those around UHMWPE and pure PEEK. CONCLUSIONS: The HA/PEEK biocomposite created by a compounding and injection-molding technique exhibited enhanced osteogenesis and could be used as a candidate of orthopedic implants.

Violence in the Early Bronze Age. Diagnosis of skull lesions using anthropological, taphonomic and scanning electron microscopy techniques.

In this paper we present the study of a skull belonging to a young male from the Italian Bronze Age showing three perimortem injuries on the frontal and parietal bones; the peculiarity of the frontal injury is represented by its singular shape, which may be indicative of the weapon that caused the lesion. The aim of the present study is to examine the traumatic evidence in relation to possible etiological factors, in order to attempt to establish if the lesion occurred peri or post-mortem, and to evaluate if these traumatic injuries could be interpreted as an evidence of interpersonal violence, by combining anthropological, taphonomic and ESEM investigations. The combination of multidisciplinary methods of study can provide important new insights into inter-personal violence.

Long-term self-inflicted craniocerebral penetrating injury with a fatal outcome.

A case of long-term continual self-inflicted penetrating craniocerebral injury to a 59-year-old man with a fatal outcome is reported. The man suffered from paranoid psychosis and alcohol dependence. Over five months, he continually scalped the skin and subcutaneous tissue of his head with a knife until he perforated the skull and dura mater and injured his brain. He eventually sought medical advice, but died after 10 days of hospitalization despite complex conservative treatment. The immediate cause of death was a combination of central nervous system failure and heart failure. The original case presented is sporadic in the forensic literature due to atypical long-term continual self-harm to the head and brain using a sharp object that resulted in perforation of the skull and a fatal outcome. This case also highlights the importance of autopsy to determine the mechanism of injury and cause of death.

Spontaneous resolution of a 'ping-pong' fracture at birth.

'Ping-pong' fractures are depressed skull fractures in newborn infants that occur as inward buckling of the calvarial bones, forming a cup shape. These fractures are often associated with maintenance of bone continuity. These fractures may occur spontaneously during the intrauterine period or secondary to birth trauma. Currently, there is no standard protocol for the management of depressed skull fractures. Neurosurgical or non-surgical approaches may be administered depends on the severity of the fracture. Most untreated ping-pong fractures resolve spontaneously within 6 months. Therefore, it is recommended to reserve surgical elevation or non-surgical techniques for infants not demonstrating spontaneous resolution during this period. In addition, neurosurgical interventions are usually considered for cases with intracranial pathology or neurological deficits or for infants who do not respond to conservative treatment. Herein, we report a case of a newborn infant with a spontaneous intrauterine ping-pong fracture, which spontaneously resolved, without surgical or non-surgical intervention.

Management of Penetrating Brain Injury Caused by a Nail Gun: Three Case Reports and Literature Review.

BACKGROUND: Penetrating brain injury (PBI) caused by a nail gun is an extremely rare neurosurgical emergency that poses a challenge for neurosurgeons because of its rarity and complexity. CASE DESCRIPTION: Here we present 3 cases of PBI caused by a nail gun. In the first case, the nail entered through the right parietal bone and lodged in the right parietal lobe and basal ganglia. In the second case, the nail entered through the right occipital bone and lodged in the right occipital lobe. In the third case, the nail entered through the right parietal bone and lodged in the right frontal and parietal lobes. All patients underwent surgical removal of the nail. The first patient presented with reduced left-side strength, whereas the second and third patients were neurologically intact on presentation. CONCLUSIONS: PBI caused by a nail gun can present with differing clinical manifestations, and most cases require immediate surgery. A rational management strategy should provide a good postoperative prognosis with minimal neurologic deficits in these patients.

Osteogenesis of Crouzon-Mutated Cells in an Experimental Model.

Crouzon syndrome is an autosomal-dominant congenital disease due to a mutation in the fibroblast growth factor receptor 2 protein. The purpose of this study is to evaluate wound-healing potential of Crouzon osteoblasts and adipose-derived stem cells (ADSCs) in a murine model. Parietal skull defects were created in Crouzon and mature wild-type (WT) CD-1 mice. One group of WT and Crouzon mice were left untreated. Another group was transplanted with both WT and Crouzon adipose-derived stem cells. Additional groups compared the use of a fibrin glue scaffold and periosteum removal. Skulls were harvested from each group and evaluated histologically at 8-week and/or 16-week periods. Mean areas of defect were quantified and compared via ANOVA F-test. The average area of defect after 8 and 16 weeks in untreated Crouzon mice was 15.37 ±â€Š1.08 cm and 16.69 ±â€Š1.51 cm, respectively. The average area of the defect in untreated WT mice after 8 and 16 weeks averaged 14.17 ±â€Š1.88 cm and 14.96 ±â€Š2.26 cm, respectively. WT mice with autologous ADSCs yielded an average area of 15.35 ±â€Š1.34 cm after 16 weeks while Crouzon mice with WT ADSCs healed to an average size of 12.98 ±â€Š1.89 cm. Crouzon ADSCs transplanted into WT mice yielded an average area of 15.47 ±â€Š1.29 cm while autologous Crouzon ADSCs yielded an area of 14.22 ±â€Š3.32 cm. ANOVA F-test yielded P = .415. The fibroblast growth factor receptor 2 mutation in Crouzon syndrome does not promote reossification of critical-sized defects in mature WT and Crouzon mice. Furthermore, Crouzon ADSCs do not possess osteogenic advantage over WT ADSCs.

Photobiomodulation of mesenchymal stem cells encapsulated in an injectable rhBMP4-loaded hydrogel directs hard tissue bioengineering.

Photobiomodulation (PBM) therapy displays relevant properties for tissue healing and regeneration, which may be of interest for the tissue engineering field. Here, we show that PBM is able to improve cell survival and to interact with recombinant human Bone Morphogenetic Protein 4 (rhBMP4) to direct and accelerate odonto/osteogenic differentiation of dental derived mesenchymal stem cells (MSCs). MSCs were encapsulated in an injectable and thermo-responsive cell carrier (Pluronic® F-127) loaded with rhBMP4 and then photoactivated. PBM improved MSCs self-renewal and survival upon encapsulation in the Pluronic® F-127. In the presence of rhBMP4, cell odonto/osteogenic differentiation was premature and markedly improved in the photoactivated MSCs. An in vivo calvarial critical sized defect model demonstrated significant increase in bone formation after PBM treatment. Finally, a balance in the reactive oxygen species levels may be related to the favorable results of PBM and rhBMP4 association. PBM may act in synergism with rhBMP4 and is a promise candidate to direct and accelerate hard tissue bioengineering.

A Unique Type of Birth Trauma Mistaken for Abuse.

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction-related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.

Calcium-containing scaffolds induce bone regeneration by regulating mesenchymal stem cell differentiation and migration.

BACKGROUND: Osteoinduction and subsequent bone formation rely on efficient mesenchymal stem cell (MSC) recruitment. It is also known that migration is induced by gradients of growth factors and cytokines. Degradation of Ca2+-containing biomaterials mimics the bone remodeling compartment producing a localized calcium-rich osteoinductive microenvironment. The aim of our study was to determine the effect of calcium sulfate (CaSO4) on MSC migration. In addition, to evaluate the influence of CaSO4 on MSC differentiation and the potential molecular mechanisms involved. METHODS: A circular calvarial bone defect (5 mm diameter) was created in the parietal bone of 35 Balb-C mice. We prepared and implanted a cell-free agarose/gelatin scaffold alone or in combination with different CaSO4 concentrations into the bone defects. After 7 weeks, we determined the new bone regenerated by micro-CT and histological analysis. In vitro, we evaluated the CaSO4 effects on MSC migration by both wound healing and agarose spot assays. Osteoblastic gene expression after BMP-2 and CaSO4 treatment was also evaluated by qPCR. RESULTS: CaSO4 increased MSC migration and bone formation in a concentration-dependent manner. Micro-CT analysis showed that the addition of CaSO4 significantly enhanced bone regeneration compared to the scaffold alone. The histological evaluation confirmed an increased number of endogenous cells recruited into the cell-free CaSO4-containing scaffolds. Furthermore, MSC migration in vitro and active AKT levels were attenuated when CaSO4 and BMP-2 were in combination. Addition of LY294002 and Wortmannin abrogated the CaSO4 effects on MSC migration. CONCLUSIONS: Specific CaSO4 concentrations induce bone regeneration of calvarial defects in part by acting on the host's undifferentiated MSCs and promoting their migration. Progenitor cell recruitment is followed by a gradual increment in osteoblast gene expression. Moreover, CaSO4 regulates BMP-2-induced MSC migration by differentially activating the PI3K/AKT pathway. Altogether, these results suggest that CaSO4 scaffolds could have potential applications for bone regeneration.

Variation in management of in-hospital newborn falls: a single-center experience.

OBJECTIVE There are only 3 small case series in the literature that report on the management of in-hospital newborn falls (NFs), and recommendations are unclear. The authors performed a retrospective review to determine outcome and differences in management and to understand why management of NFs varies at their institution. METHODS All NFs occurring within the authors' institution over a 3.5-year period were reviewed. Post-fall management and outcomes of each incident were compared. RESULTS There were 24 NFs out of 40,349 deliveries (5.9 NFs/10,000 deliveries). The mechanism of injury was nearly identical in 22 of 24 falls (the newborn fell to the floor from a parent in a bed or chair), and physical examination findings were normal or benign in all cases. Unexplained management variation based solely on clinician preference was noted, including observation only (in 13 cases), skull radiograph (in 7), head CT scan (in 6), bone survey (in 4), and head ultrasound examination (in 1), with some babies having more than 1 study. Two babies had nondepressed linear parietal fractures diagnosed by skull radiograph, and 2 babies had small subdural hemorrhages diagnosed by head CT scan. All 24 babies had normal findings on examination at discharge. CONCLUSIONS There is a high incidence of nondepressed linear parietal skull fractures associated with NFs. However, since associated intracranial injury is uncommon, imaging studies may not be routinely performed. Neonatal intensive care unit admission, head CT, and neurosurgical evaluation are reserved for the rare baby with abnormal physical examination or neurological findings.

Coma prolongado: a propósito de un caso con recuperación de la conciencia tras seis meses / Prolonged coma: report of a case with good recovery of consciousness after six months

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Biparietal Thinning: Accidental Death by a Fall from Standing Height.

Biparietal thinning resulting in bilateral and symmetrical resorption and loss of thickness of the parietal bones is an uncommon to rare condition in the anthropological and clinical literature. This enigmatic condition of unknown etiology was first reported in the 18th century and has been variously described as a nonmetric trait, anatomical variant, anomaly, and pathology. Biparietal thinning presents grossly and radiographically as oval-shaped depressions in 0.25-0.8% and 0.4-0.5% of individuals and with a higher frequency in females over the age of 60 years. A review of the literature revealed only one example of cranial trauma associated with biparietal thinning and none of fatal trauma associated with this condition. This case reports a rare example of fatal trauma in an elderly man that resulted from a backward fall from a standing height and highlights the increased risk of craniocerebral trauma in individuals with this condition.