A Pediatric Radiology Textbook and Pediatric Radiology Digital Library
Pediatric Skull Fracture
Etiology: Trauma
Imaging Linear Skull Fracture: — Simple fracture with the skull fragments closely approximated
Imaging Complex Skull Fracture: — Complex fracture with the skull fragments spread apart
Imaging Diastatic Skull Fracture: — Unique type of skull fracture affecting children involving cranial sutures — Can be difficult to diagnose – look for asymmetry in sutures, coronal and sagittal and 3D reformats can help to identify them — Can be associated with intracranial hemorrhage
Imaging Depressed Skull Fracture: — Complex fracture with the skull fragments entering into the cranium — Significantly depressed skull fractures are associated with lacerations of the brain
Imaging Ping Pong Skull Fracture: — Etiology is depression of plastic fetal skull against maternal sacral promontory or forceps — Results in depressed or inward buckling skull fracture without a fracture line that occur uniquely in neonates due to the high water content and soft nature of their bones — Often associated with birth trauma — Usually not associated with intracranial findings — Clinically resolve spontaneously
Imaging Growing Skull Fracture (Leptomeningeal cyst): — Etiology is following diastatic fracture the dura is interrupted and there is erosion of fracture edges due to cerebrospinal fluid pulsation — Clinically is unique to infants less than 3 years old
Imaging Healing Skull Fracture: — Skull fracture which involve membranous bone heals without periosteal reaction and slowly disappears
Note: Scalp soft tissue swelling can be a sign of unsuspected skull fracture, pneumocephalus after trauma is associated with a skull fracture
Note: If air or fracture is present near a vascular foramen in head or neck a CT angiogram should be performed to look for vascular injury
Note: Multiplanar CT 2D reformats often helpful as skull fractures may be more visible in coronal or sagittal planes, CT 3D reformatted images help to better identify skull fractures
DDX: — Accessory cranial suture which should be jagged while fractures should be smooth, symmetric skull fractures can mimic sutures so it is important to know normal and variant sutural anatomy — Vascular groove — Wormian bones
Complications: — Epidural hematomas are associated with skull fracture — In setting of trauma intracranial air suggests a fracture involving a sinus leading to a dirty fracture with increased risk of intracranial infection
Treatment: Skull fractures with depression greater than 1 centimeter requires urgent neurosurgical correction
Clinical:
Radiology Cases of Skull Fracture
Radiology Cases of Linear Skull Fracture
Lateral radiograph of the skull shows bilateral linear parietal lucencies coursing across the skull.AP radiograph of the skull shows a linear lucency in the left parietal bone that connects to the left lambdoid suture. Axial CT without contrast of the brain shows bilateral low density extra-axial fluid collections around the brain.AP and lateral radiographs of the skull show numerous branching lucencies in the right parietal bone. Axial CT without contrast of the brain shows high density material in the right subgaleal tissues, a small high density cresenteric fluid collection in the right extra-axial space that extends posteriorly along the falx, and a mixed low-density and high density lesion in the right posterior parietal brain parenchyma.3D reconstruction from CT without contrast of the brain (left) shows a linear straight lucency that connects to the left lambdoid suture. Coronal CT (right) shows the same linear lucency lying under a large subgaleal hematoma.
Radiology Cases of Diastatic Skull Fracture
3D reconstruction from a CT without contrast of the brain shows a wide right parietal lucency between two separated fragments of bone.
Initial lateral radiograph of the skull (above) shows a stellate skull fracture in the parietal bone. Some of the skull fragments are also diastatic, or spread apart. Followup lateral radiograph of the skull obtained 3 weeks later (below) shows a widening distance between several of the skull fragments.3D CT without contrast of the skull shows bilateral almost symmetrical transverse and longitudinal fractures in the parietal bones.Axial CT without contrast of the brain shows high density material in the subgaleal tissues posteriorly, a wide lucency in the right posterior skull along with two areas of depressed lucency in the left frontal skull, a rounded high-density lesion in the midline of the cerebellum, and decreased density of the cerebrum when compared to the normal density of the cerebellum along with loss of the normal gray matter-white matter differentiation.
Radiology Cases of Depressed Skull Fracture
Axial CT without contrast of the brain shows depression of the skull in the left temperoparietal region with an associated subgaleal hematoma containing subcutaneous air.Axial CT without contrast of the brain shows a left parietal depressed skull fracture with high density material in the adjacent subgaleal space that crosses sutures and courses around to the right side of the skull.
Radiology Cases of Ping Pong Skull Fracture
Axial (above left) and coronal (above right) CT without contrast of the brain show a depression in the left side of the skull. There was no intracranial hemorrhage. The depression is better seen on the 3D CT (below).
Radiology Cases of Growing Skull Fracture
3D CT reconstruction initially (left) showed a diastatic skull fracture which has increased in size on the lateral radiograph of the skull (right) taken 2 months later.Initial lateral radiograph of the skull (above) shows a stellate skull fracture in the parietal bone. Some of the skull fragments are also diastatic, or spread apart. Followup lateral radiograph of the skull obtained 3 weeks later (below) shows a widening distance between several of the skull fragments.
Radiology Cases of Healing Skull Fracture
Lateral radiograph of the skull initially (left) showed bilateral linear parietal lucencies coursing across the skull which are no longer seen 4 months later (right).
