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Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 52-54

Spontaneous skull fracture in a term infant

1 Department of Pediatrics and Neonatology, Tanta University Hospital, Tanta, Egypt; Department of Pediatrics and Neonatology, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
2 Department of Pediatrics and Neonatology, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

Date of Submission28-Aug-2021
Date of Decision30-Oct-2021
Date of Acceptance03-Nov-2021
Date of Web Publication03-Jan-2022

Correspondence Address:
Wegdan Mawlana
Department of Pediatrics and Neonatology, Tanta University Hospital, Tanta

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.jcn_109_21

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Instrumental delivery is the most common cause of skull fracture in neonates. We report a depressed fracture with massive intracranial hemorrhage in a term female infant born by unassisted cesarean section after unremarkable pregnancy.

Keywords: Convulsion, depressed skull fracture, intracranial hemorrhage, neonates

How to cite this article:
Mawlana W, Gharib M, Osman A. Spontaneous skull fracture in a term infant. J Clin Neonatol 2022;11:52-4

How to cite this URL:
Mawlana W, Gharib M, Osman A. Spontaneous skull fracture in a term infant. J Clin Neonatol [serial online] 2022 [cited 2022 Aug 8];11:52-4. Available from: https://www.jcnonweb.com/text.asp?2022/11/1/52/334728

  Introduction Top

Neonatal depressed fracture of the skull is rare, with an incidence of 1 in 10,000 births. Most of these fractures occur due to birth trauma associated with instrumental delivery.[1] Intracerebral hemorrhage in term neonates has been also reported after vacuum- or forceps-assisted delivery.[2] We present a female neonate with skull fracture associated with massive intracranial bleeding that occurred spontaneously after unassisted cesarean section.

  Case Report Top

A full-term baby girl was born at 38+5 weeks' gestation with a birth weight of 2.90 kg. She was born to 28-year-old primigravida with blood group O positive and rubella immune, and other serologies were nonreactive. She had an unremarkable medical history with no social issues. The mother had spontaneous rupture of the membrane 41 h prior to delivery. She received three doses of ceftazidime (the mother was allergic to ampicillin). Labor was induced for 5 h with slow descent of the head. The baby developed low scalp pH (7.19) and nonreassuring cardiotocography. The mother was pushed to emergency cesarean section. No forceps or vacuum extractor was used. APGAR score was 2, 6, 7, and 7 at 1, 5, 10, and 20 min, respectively, needed initial steps of resuscitation and positive pressure ventilation for 30 seconds. Cord pH (umbilical artery) was 7.10 and (umbilical vein) 7.16. On examination, the baby was lethargic and had weak Moro and sucking reflexes. Pupils were sluggish and reactive to light, normal tone. There were no abnormal movements. There were two small skull swelling bilaterally in the parietal areas.

In neonatal intensive care unit, the baby was connected to biphasic continuous positive airway pressure. Initial blood gas within the 1st h showed pH 7.28, PCO2 28, HCO3 13, and BD -10. After 1 h, the baby was active, moving all limbs, normal tone, good Moro, and sucking reflexes. The baby did not meet the criteria for therapeutic hypothermia as per our guidelines. On the next day, the baby was weaned to room air, started oral feeding. However, after 24 h, she developed focal right-sided tonic-clonic seizures which were controlled by loading dose phenobarbitone followed by maintenance doses. Urgent computed tomography (CT) brain showed depressed skull fracture at the left temporoparietal area with epidural hemorrhage, subarachnoid hemorrhage, and subgaleal hematoma [Figure 1]. Neurosurgery consultation was done, and he advised for conservative management. All laboratory investigations to rule out bleeding disorders came back negative: PT 12.7 s, PTT 29.5 s, INR 0.92, Von Willbrand factor 145% (6–160), factor XIII 80% (70–150), and D-dimer 0.25 (0–0.5) μg/ml. Repeated CT brain on the 3rd day of life showed a decreasing size of hemorrhage [Figure 2]. By day 7 of life, the baby was hemodynamically stable and had normal neurologic examination, ad-lib feeding, and no seizures. She was discharged home on maintenance dose of phenobarbitone with scheduled appointment with pediatric neurology and neurosurgery. At the age of 6 weeks, the patient was doing well with appropriate neurologic examination and no seizures. CT showed resolved intracranial bleed with no fracture seen [Figure 3]. Pediatric neurology advised to continue on phenobarbitone for another 3 months. Follow-up visit at the age of 6 months showed normal neurologic examination and appropriate neurodevelopment for her age. Parents were reassured about the long-term outcome.
Figure 1: (a and b) Left high parietal epidural hemorrhage of maximum thickness about 1.1 cm. Left high parietal fracture line with minimal about 2-mm bony depression. Multiple subarachnoid linear hyperdensities suggesting hemorrhage. Small hyperdensity is suspected at right frontal lobe could represent?? Hemorrhage. Effacement of sulci, fissures, and cerebrospinal fluid spaces, may represent diffuse brain edema. Mild biparietal subgaleal hematoma is noted

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Figure 2: (a and b) The previously noted left high parietal extra-axial/epidural hematoma is mildly decreased in thickness. The diffuse effacement of the sulci and fissures is resolved. The subgaleal hematoma is regressed as well. The small left temporal hematoma and the other multiple linear, curvilinear, and tiny dot of hemorrhage became more obvious recently

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Figure 3: The previously noted left high parietal extra-axial/epidural hematoma is no longer seen. The subgaleal hematoma is resolved. The small left temporal hematoma and the other multiple linear, curvilinear, and tiny dot of hemorrhage resolved. No evidence of fracture

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  Discussion Top

Most of the skull fractures occur due to instrumental delivery or pressure during obstetric maneuvers in a difficult delivery.[3] Skull fracture is considered a spontaneous fracture if no apparent cause is identified as presented in our case. Our baby was born by unassisted cesarean section after failure to progress. This may have happened spontaneously in utero due to the pressure of the ischial tuberosity and the pubic bones on the fetal head.[4] Skull fracture is quite common in the temporoparietal skull bones as these bones are soft, flexible with incomplete mineralization.[5] Among the most common birth trauma of the skull are caput succedaneum, cephalohematoma, and subgaleal bleeding. Rarely, skull fractures are seen. Our patient presented with epidural hemorrhage, subarachnoid hemorrhage, and subgaleal hematoma in addition to the skull fracture. Intracranial hemorrhage in full-term infants is an important cause of morbidity and mortality.[6]

Most of the skull fractures are diagnosed after birth. The presence of an abnormal skull depression observed at clinical examination at birth is the key for the diagnosis, but our patient rather presented with swelling in the temporoparietal area (cephalohematoma) which could mask the diagnosis. However, when the baby developed focal clonic seizures, this mandated urgent CT which surprisingly showed epidural, subarachnoid, and subgaleal hemorrhage with small depressed fracture. CT head is the gold standard to diagnose skull fracture and any associated brain injury and hemorrhage.[7] If findings on CT are not conclusive, magnetic resonance imaging should be done.

Management of skull fracture varies according to the associated factors; conservative management as happened in our case, nonsurgical procedure as vacuum device in case of depressed fracture, or surgical intervention in special cases may be required.[8],[9],[10],[11] In the study by Dupuis et al., they reported that spontaneous skull fracture had good prognosis while fracture due to traumatic delivery may impact long-term developmental outcome.[12] Our patient was followed at 3 and 6 months of life. She had normal neurologic examination and no seizures, and her development was appropriate for her age.

  Conclusion Top

Although the prognosis for spontaneous skull fracture is relatively good and most of the cases resolve without any neurological sequelae, it poses medicolegal implications for the medical team.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Doumouchtsis SK, Arulkumaran S. Head injuries after instrumental vaginal deliveries. Curr Opin Obstet Gynecol 2006;18:129-34.  Back to cited text no. 1
Hong HS, Lee JY. Intracranial hemorrhage in term neonates. Childs Nerv Syst 2018;34:1135-43.  Back to cited text no. 2
Brittain C, Muthukumar P, Job S, Sanka S. 'Ping pong' fracture in a term infant. BMJ Case Rep 2012;2012:bcr0120125631.  Back to cited text no. 3
Aliabadi H, Miller J, Radnakrishnan S, Mehta AI, Thomas K, Selznick L, et al. Spontaneous intrauterine “ping-pong” fracture: Review and case illustration. Neuropediatrics 2009;40:73-5.  Back to cited text no. 4
Suneja U, Prokhorov S, Kandi S, Rajegowda B. Depressed skull fracture in a term newborn infant. Pediatr Ther 2015;5:4.  Back to cited text no. 5
Preston D, Jackson S, Gandhi S. Non-traumatic depressed skull fracture in a neonate or 'ping pong' fracture. BMJ Case Rep 2015;2015:bcr2014207077.  Back to cited text no. 6
Mutch CA, Talbott JF, Gean A. Imaging evaluation of acute traumatic brain injury. Neurosurg Clin N Am 2016;27:409-39.  Back to cited text no. 7
Ou-Yang MC, Huang CB, Huang HC, Chung MY, Chen CC, Chen FS, et al. Clinical manifestations of symptomatic intracranial hemorrhage in term neonates: 18 years of experience in a medical center. Pediatr Neonatol 2010;51:208-13.  Back to cited text no. 8
Doria M, Viveiros C, Rodrigues LR, Soares F. A rare case of spontaneous intrauterine skull fracture. Acta Med Port 2020;33:344-6.  Back to cited text no. 9
Djientchev DV, Nizamnsh AK, Ongolo-Zago P, Ako S, Essomba A, Sosso MA. Depressed skull fracture in children, treatment using an obstetrical vacuum extractor. Pediatr Neurosurg 2006;42:273-6.  Back to cited text no. 10
Zalatimo O, Ranasinghe M, Dias M, Iantosca M. Treatment of depressed skull fractures in neonates using percutaneous microscrew elevation. J Neurosurg Pediatr 2012;9:676-9.  Back to cited text no. 11
Dupuis O, Silveira R, Dupont C, Mottolese C, Kahn P, Dittmar A, et al. Comparison of “instrument-associated” and “spontaneous” obstetric depressed skull fractures in a cohort of 68 neonates. Am J Obstet Gynecol 2005;192:165-70.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]


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