Non-traumatic depressed skull fracture in a neonate or ‘ping pong’ fracture

Abstract

SUMMARYThis is a case study describing the finding of a depressed skull fracture in a neonate who was delivered without instrumentation and with no history of trauma. Depressed skull fractures are described as being associated with forceps delivery both vaginally and with caesarean section but are much rarer without instrumentation. This obvious abnormality was very concerning for the parents as it was not picked up on antenatal scans and there was no clear cause. There were both cosmetic and neurological concerns and we found no clear consensus on appropriate treatment and prognosis in the literature we had available. BACKGROUND

Spontaneous resolution of a ‘ping-pong’ fracture at birth

“…Ping-pong fractures most commonly involve the frontal, parietal and occipital bones. Due to immature ossification, prolonged focal pressure on a neonatal skull may lead to ping-pong fractures, with indentation of the bone surface and undisrupted bone continuity 3. Trauma-related ping-pong fractures are often the result of instrument-assisted deliveries, involving the use of forceps, exposure of the head to pressure from the pelvis during delivery or exposure to extensive pressure while pushing up the head during caesarean section 4.…”

Spontaneous ping-pong parietal fracture in a newborn

“…The fetal head during the third trimester of pregnancy is completely protected by the surrounding bony structures. Therefore, it is unlikely that an impact, without maternal pelvic injuries (uterine myoma or tumour), would be responsible for a fetal skull fracture 3. Other mechanisms related to the fetus itself include skull compression by a twin or pressure exerted by the digits and fists of the newborn on his skull 4.…”

“…Watchful waiting can be advised since many fractures can elevate themselves spontaneously 2 3. Conservative treatment often result in spontaneous resolution within 4 months 2.…”

Massive congenital depression of neonate’s skull

“…Regarding treatment of isolated SD, spontaneous resolution may usually be obtained with a conservative treatment with watchful waiting during the first 4–6 months of life 4. Neurosurgical elevation and non-surgical reduction using vacuum elevation may also be indicated 4.…”

“…Neurosurgical elevation and non-surgical reduction using vacuum elevation may also be indicated 4. The decision to perform a neurosurgical treatment is based on the severity of SD (important size, depression >1 cm), a potential underlying brain injury and a non-resolution after 6 months of conservative treatment 4 5.…”