Decision-Making Challenge of Ping-Pong Fractures in Children: Case Exemplification and Systematic Review of Literature

Altieri, Roberto; Grasso, Erica; Cammarata, Giacomo; Garozzo, M.; Marchese, Gianmarco; Certo, Francesco; Ruggieri, Martino; Falsaperla, Raffaele; Barbagallo, Giuseppe

doi:10.1016/j.wneu.2022.05.130

Cited by 5 publications

(7 citation statements)

References 52 publications

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“…The depth of the fracture seemed to be an important factor in the success of vacuum elevation, as others have reported [ 8 ]. There was a trend toward the deepest fractures in this group requiring a second vacuum attempt.…”

Section: Discussionmentioning

confidence: 74%

“…Recently, vacuum-assisted elevation has been described as a viable treatment option [ 5 – 7 ]. Multiple studies have shown that the following scenarios may necessitate surgical repair: the presence of a foreign body, debris, or infected tissue in a wound, cerebrospinal fluid leak, presence of a hematoma, increased intracranial pressure, neurological impairment, esthetic considerations, and presence of a hygroma [ 8 ]. Though presentations such as these may necessitate surgical repair, it is desirable to avoid surgical intervention whenever possible due to the inherent potential risks associated with opening the cranium and the use of general anesthesia, particularly in neonates and infants [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

“…There is a limited number of publications reviewing the outcomes of patients with depressed skull fractures corrected by suction-assisted elevation [ 8 , 10 , 15 ]. In this report, we review the outcomes of seven pediatric patients with ping pong fractures treated at our institution with suction elevation.…”

Section: Introductionmentioning

confidence: 99%

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Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

Ahmed,

Allhusen,

Muhonen

et al. 2024

Childs Nerv Syst

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Purpose Depressed (“ping-pong”) skull fractures can be treated by different means, including observation, non-surgical treatments, or surgical intervention. The authors describe their experience with vacuum-assisted elevation of ping-pong skull fractures and evaluate variables associated with surgical outcomes. Methods The authors present a retrospective review of all ping-pong skull fractures treated with vacuum-assisted elevation at the Children’s Hospital of Orange County in 2021–2022. Variables included patient age, mechanism of injury, fracture depth, bone thickness at the fracture site, and degree of elevation. Results Seven patients underwent vacuum-assisted elevation of ping-pong fractures at the bedside without the use of anesthesia. Fractures caused by birth-related trauma were deeper than those caused by falls (p < 0.001). There was no significant difference between groups in bone thickness at the fracture site (2.10 mm vs 2.16 mm, n.s). Six of the seven patients experienced significant improvement in fracture site depression, with four displaying a complete fracture reduction and two displaying a significant reduction. The degree of fracture reduction was modestly related to the depth of fracture, with the two deepest fractures failing to achieve full reduction. Age appeared to be related to fracture reduction, with the lowest reduction observed in one of the oldest patients in this sample. No complications were observed in any patient other than temporary mild swelling at the suction site, and no re-treatment or surgery for the fractures was required. Conclusion Vacuum-assisted elevation of ping-pong skull fractures is a safe and effective noninvasive treatment option for infants that can be used under certain circumstances. The procedure can be done safely at the bedside and is a relatively quick procedure. It avoids the need for open surgical intervention, anesthesia, or hospital admission, and can lead to excellent outcomes.

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Section: Discussionmentioning

confidence: 74%

Section: Introductionmentioning

confidence: 99%

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Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

Ahmed,

Allhusen,

Muhonen

et al. 2024

Childs Nerv Syst

View full text Add to dashboard Cite

show abstract

“…Recently, vacuum-assisted elevation has been described as a viable treatment option [4][5][6]. Multiple studies have shown that the following scenarios may necessitate surgical repair: presence of a foreign body, debris, or infected tissue in a wound, cerebrospinal uid leak, presence of a hematoma, increased intracranial pressure, neurological impairment, aesthetic considerations, and presence of a hygroma [7]. Though presentations such as these may necessitate surgical repair, it is desirable to avoid surgical intervention whenever possible due to the inherent potential risks associated with opening the cranium and the use of general anesthesia, particularly in neonates and infants.…”

Section: Introductionmentioning

confidence: 99%

Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

Ahmed,

Allhusen,

Muhonen

et al. 2023

Preprint

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Purpose Depressed (“ping-pong”) skull fractures can be treated by different means and the outcomes for children treated with vacuum-assisted elevation are comparable to surgical treatment. Methods We present a retrospective review of all ping-pong skull fractures treated with vacuum-assisted elevation at Children’s Hospital of Orange County in 2021-22. Variables included patient age, mechanism of injury, fracture depth, bone thickness at fracture site, and degree of elevation. Results Seven patients underwent vacuum-assisted elevation of ping-pong fractures bedside without the use of anesthesia. Fractures caused by birth-related trauma were deeper than those caused by falls (p < .001). There was no difference between groups in bone thickness at the fracture site (2.10mm vs 2.16mm, n.s). Six of the seven patients experienced significant improvement in fracture site depression, with four displaying a complete fracture reduction and two displaying significant reduction. Degree of fracture reduction was modestly related to depth of fracture, with the two deepest fractures failing to achieve full reduction. Age appeared to be related to fracture reduction, with the lowest reduction observed in one of the oldest patients in this sample. No complications were observed in any patient other than temporary mild swelling at the suction site, and no re-treatment or surgery for the fractures was required. Conclusion Vacuum-assisted elevation of ping-pong skull fractures is a safe and effective treatment option for infants under certain circumstances and has many benefits. The procedure can be safely done at the bedside, avoids the need for open surgical intervention, anesthesia, or hospital admission, and is a relatively quick procedure.

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“…However, the time and uncertainty associated with the hope of potential spontaneous resolution can create understandable anxiety for the patients' parents. 4 In other patients, the cosmetic appearance can be quite noticeable, and indentation of the bone in larger PPF can cause local mass effect on the adjacent brain. In these circumstances, surgical correction may be achieved through a small craniotomy or by creating an adjacent burr hole and elevating the fracture with a Penfield dissector.…”

mentioning

confidence: 99%

Elevation of Depressed Skull Fracture in Neonates Using a Breast Pump and a Custom-Molded Flange

Martinez,

Welscher,

Shah

et al. 2024

Operative Neurosurgery

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BACKGROUND AND IMPORTANCE: “Ping-pong fractures” (PPF) can occur in neonates and result in cosmetic deformity and local mass effect. Standard treatment involves surgical elevation of the depressed bone when the indentation is considerable or cosmetically apparent. Surgical correction of PPF subjects patients to the risks of surgery and general anesthesia. This article and corresponding video demonstrate a novel means of correcting PPF at bedside without surgery or anesthesia. We used a hospital-grade breast pump connected to a custom-fabricated flange to successfully elevate PPF in two neonates. CLINICAL PRESENTATION: Two moderately preterm infants were noted at birth to have large parietal PPF. To avoid surgical intervention, elevation using a suction device was attempted. A hospital-grade breast pump was used to provide suction. A custom device was fabricated out of a breast pump flange and molded Coloplast Brava® protective seal rings. This device was carefully applied to the skull to exactly match the diameter of the PPF and contour of the bone. Brief (15-30 seconds) periods of suction were applied several times until the PPF was successfully elevated as documented on subsequent computed tomography scans. Both infants achieved excellent cosmetic results with no adverse effects over 24- and 9-month follow-ups, respectively. DISCUSSION: This technique eliminates the risks of open surgical correction and corrected the PPF without general anesthesia or adverse effects to the infant. While there may be limitations due to patient age and/or location of the PPF, the use of widely available and inexpensive custom-fitted materials with a hospital grade breast pump achieves maximal efficacy without requiring higher negative pressure suction application. CONCLUSION: Elevation of PPF can be safely achieved in some neonates using readily available equipment: a hospital-grade breast pump, flange, and moldable adherent material. This technique is reasonable to attempt in lieu of surgical elevation.

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Decision-Making Challenge of Ping-Pong Fractures in Children: Case Exemplification and Systematic Review of Literature

Cited by 5 publications

References 52 publications

Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

Pediatric ping-pong skull fractures treated with vacuum-assisted elevation

Elevation of Depressed Skull Fracture in Neonates Using a Breast Pump and a Custom-Molded Flange

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