Calvarial Fractures (Cerebral Concussion)

Swellings restricted to the region of one bone of the calvarium are indications of linear calvarial fractures; in infants and toddlers between 6 and 24 months, the incidence of linear skull fractures is much higher than later in life; often, these young patients have no clinically recognizable disturbance of consciousness. Figure comm_14a_n.jpg: Types of linear fractures of the calvarium in infants (Choux M. In: Head injury in the newborn and infant. Berlin: Springer,1986). From the top of the left side to the bottom of the right side: Linear fracture which goes from one lateral suture to another lateral suture. Fracture running from one lateral suture to the sagittal suture. A fracture which starts from one suture and ends within one bone. Rupture of one suture, in the drawing rupture of the coronal suture. comm_14a2_n.jpg: This lateral skull x-ray exhibits a continuously widening line which originates from the posterior parietal bone and runs to the right lambdoid suture. Diagnosis: Right-sided transverse parietal skull fracture. The clinical significance may differ depending on the child's age and the site of the fracture. Figure comm_14b1_n.jpg: From a psychological point of view, it is annoying if a mother feels a scalp swelling with a central dent for some days after consultation of a general practitioner, and a linear skull fracture is visible on the x-ray performed at the emergency department. 2-year-old girl with whom the mother already has consulted a practitioner due to a fall a few days ago, and in whom she found a grotesque swelling of the head during hair dressing. In the posterior half of the right parietal region, a bluish swelling is recognizable which is limited to the underlying bone. Notice the contours of the soft tissue starting from the region where the hair is combed in an anterior as well as in a posterior direction. The corresponding x-ray is depicted in comm_14a2_n.jpg. The diagnosis is a subacute subperiostal hematoma following a right-sided parietal skull fracture. (I owe these pictures to V. Oesch, Department of Pediatric Surgery (Prof. Z. Zachariou), Inselspital CH-Bern). $$epid_16??nr=1££See alternate figure.§§ Figure comm_14b2a_n.jpg and figure comm_14b2b_n.jpg: In general, occipital fractures close to the sigmoid sinus as shown in a Towne projection of the skull (as well as vertical fractures crossing the midline, and transverse parietal fractures) need special supervision due to the danger of intracranial hemorrhage. In this child an additional CT was performed which shows the extent of the fracture and no intracranial hemorrhage. 2-year-old boy with an occipital contusion and abrasion following a fall; basal roentgenogram (Towne) for demonstrating the region where a fracture is expected: Longitudinal occipital fracture which starts from the left lambdoid suture, crosses the impression of the sigmoid sinus, and runs to the occipital formamen. The CT confirms the course of the fracture and excludes an infratentorial intracranial hematoma. Figure comm_14b3_n.jpg: The dimensions or type of calvarial fractures may be an indication of battered child syndrome. In this infant with incidental injury , it is mainly the course of the fracture, running with a turn-off to the midline and crossing it to the other side which differs from the fracture types in picture comm_14a_n.jpg and comm_14a2_n.jpg. Figure comm_14b4a_n.jpg to comm_14b4c_n.jpg: Anemia or even hemorrhagic shock is possible in infants due to a linear fracture combined with a major fracture hematoma. $$comm_11??££See alternate figure.§§ 2-month-old awake, extremely pale girl with an extended galea hematoma over the vertex and to the left side following head injury. Lateral skull x-ray: The wide transverse fracture starting from the left coronal suture branches both into the sagittal suture and into the left lambdoid suture. Ultrasound: Depression of the left high-parietal brain by an 8 mm thick epidural fracture hematoma. CT: Besides the midline shift to the right, there is an extended galea and subperiostal hematoma to the left. Figure comm_14b5_n.jpg: From the neonatal period to the first years of life a so-called growing skull fracture may occur due to a simultaneous laceration of the dura; in this newborn, a rectangular fracture is visible starting from the coronal to the sagittal suture; the striking feature is a diastasis of the borders of the fracture of more than 5 mm; correspondingly, a growing skull fracture and cerebral contusion was diagnosed by CT.