Ping-pong skull fracture in a neonate managed successfully with vacuum-assisted technique

Background

Ping-pong fractures (PPFs) are rare type of depressed skull fractures that occur in the fetus or newborn infants and associated with birth canal pathology and maternal trauma, but they may also happen spontaneously during the intrauterine period. ¹ PPFs caused by trauma are frequently the consequence of instrument-assisted deliveries, exposure of the head to the pelvic press during delivery, or prolonged pressure when the head is being pushed upward during a cesarean section.^2,3 Such conditions are rare, with an estimated incidence of 1–2.5 cases per 10,000 live births. ⁴ The management of PPF is not currently standardized; however, some controversial options include direct operative procedures, non-surgical skull fracture elevation, and spontaneous resolution over time. ⁵ Most of the PPFs carry a good prognosis, especially in the absence of neurological deficits. ⁶ Herein, we report a case of a term newborn infant with a ping-pong skull fracture associated with instrumental delivery, which was managed non-surgically with a vacuum extraction method.

Case summary

A 3.24 kg female newborn was delivered by a 27-year-old woman using vacuum-assisted vaginal delivery at 39 weeks of gestation. An episiotomy was performed, followed by three trials of vacuum extractions. The two initial trials were unsuccessful, with a successful delivery of the neonate in the third attempt. The neonate was transferred to the Neonatal Intensive Care Unit (NICU) for further care after an instant examination revealed a large cephalohematoma with a depression in the right parieto-occipital portion of the skull, measuring around 4 × 5 cm with approximately 4 mm depth (Figure 1).OPEN IN VIEWER

The neurological examination was unremarkable, and a brain CT was performed, which revealed a depressed skull fracture involving the right parietal calvarium, associated with subgaleal hematoma affecting the bilateral parietal and left frontal regions. However, there was no evidence of subdural/epidural hematoma and no evidence of hemorrhagic cortical contusion. Furthermore, there was no evidence of midline shift, hydrocephalus, brain herniation, acute territorial infarction, or acute hemorrhage (Figures 2 and 3).OPEN IN VIEWER

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Figure 3.

3D reconstruction of the CT scan images showing the depressed skull fracture involving the right parietal bone.

The neonate was evaluated by the neurosurgery team, and after a multidisciplinary team discussion, the decision was made to use a relatively noninvasive method employing a vacuum-assisted technique, considering the nature of the fracture, the absence of neurological impairments, and the brain CT findings. The procedure was performed at the bedside in the NICU with minimal sedation, and the right parietal region was shaved and cleaned. The neurosurgeon who performed the procedure used a Kiwi^® OmniCup^® Complete Vacuum Delivery System (Portsmouth, USA) with PalmPump-TM commonly used in the delivery room for instrumental deliveries. The device gave the managing team the advantage of controlling the suction pressure and after the application of the cup to the affected area (Figure 4), a suction pressure of 60 mm Hg was used for a few seconds (Figure 5) and then aborted using the thumb release technique.OPEN IN VIEWER

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Figure 5.

Application of controlled negative pressure to vacuum device during the procedure suction.

The non-invasive procedure used to manage this case resulted in a considerable reduction in skull depression, and the post-procedure image demonstrated a favorable outcome (Figure 6). Brain CT scan was repeated to exclude any intracranial complications (Figure 7) and demonstrated considerable resolution with minor residual depression and no recurrence of the deformity or bruises on the scalp, ruling out any parenchymal involvement.OPEN IN VIEWER

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Figure 7.

Post-vacuum extraction procedure CT scan images, showing significant resolution of depressed skull fracture with no parenchymal involvement.

Outcome and follow-up

The neonate was subsequently discharged from the NICU in a good condition and followed up in the neurosurgery outpatient clinic. At the 2-week and 1-month follow-up visits, gradual resolution of the residual depression was noticed, with complete resolution by 3 months of age. We believe that the absence of intracranial involvement played a significant effect, as the infant continued to exhibit neurological normality and met developmental milestones for his age.

Discussion

PPFs, a type of depressed skull fracture, are relatively rare in neonates due to the inherent flexibility and resilience of their skulls. It is distinguished by inward bending and buckling of the calvarial bones, which resembles indentation in a ping-pong ball on the radiograph. This phenomenon occurs from the immature ossification and the soft flexible and malleable nature of the neonatal skull and typically affects the parietal bones; however, it may involve the frontal and occipital regions. ⁷ Despite their appearance, ping-pong fractures often do not disrupt bone continuity and are like greenstick fractures in terms of injury mechanisms.^8,9 Most neonates with PPFs do not experience significant neurological sequelae nevertheless, complications may arise, particularly from the use of instrumental delivery equipment. Forceps or vacuum-assisted births, along with pressure from the birth canal, might result in further birth injuries such as epidural or subdural hemorrhage, brain contusions, and possibly long-term neurological impairments; however, such adverse outcomes are rare.^10,11

Treatment options for PPFs range from conservative management to surgical interventions. Several criteria influence the choice to proceed with surgery, including the presence of bone fragments within the brain tissues, hematomas, neurological deficits, signs of increased intracranial pressure, cerebrospinal fluid leaking, and dural penetration.^12,13 The vacuum-assisted procedure provides a non-surgical option with expected benefits such as lower infection risks, less trauma to the skull bone, quicker recovery times, and avoidance of common operative dangers. However, careful control of the applied vacuum is necessary to avoid overcorrection or worsening of the fracture.^14,15

Although literature doesn’t report significant adverse outcomes, precise application and close monitoring during and after the procedure are crucial for optimal results.^16,17 Recent research has provided promising results for non-surgical means of treating ping-pong skull fractures, including vacuum-assisted approaches. Steinbok et al. observed no significant difference in outcomes between surgical and non-surgical therapies in terms of neurological function or aesthetic appearance. ¹⁸

In our case, the vacuum-assisted technique involved applying controlled suction (60 mmHg, about 7 kilopascals) to the fractured area, which is significantly lower than the 20 kilopascals typically used in vacuum-assisted labor. Further healing over time is most likely related to the brain’s physiological development and the outward tension placed on the cranium as the infant grows. This method reduced the danger of scalp trauma and potential adverse outcomes, yielding a satisfactory cosmetic outcome for a right parietal fracture without intracranial involvement or neurological impairments. ¹⁹

A comparison of vacuum-assisted and standard neurosurgical operative methods demonstrates the advantages and disadvantages of each approach. Vacuum-assisted procedures are thought to be less invasive, lowering the risk of infection and harm to adjacent tissues; nonetheless, overcorrection or incomplete correction is the expected outcome. These procedures may not be suitable for severe or complex skull fractures that require traditional neurosurgical intervention. The surgical option allows for direct control and inspection of underlying structures but carries a higher rate of complications such as hemorrhage, infection, and risks associated with anesthesia.^20,21 When using the vacuum-assisted technique, it is critical to thoroughly assess the condition, including imaging studies to evaluate fracture extent and any associated brain injury. The device creates controlled suction to lift and reshape the depressed bone fragments, with the suction pressure carefully adjusted to prevent additional trauma. After the procedure, the neonate should be closely monitored for complications and follow-up imaging to confirm the procedure’s success. ²²

This case advances our understanding of neonatal skull fractures and the management of PPFs in the skull. The non-surgical full healing reported in our case after 3 months is consistent with other reports of spontaneous resolution of comparable fractures. Basaldella et al. reported spontaneous resolution of intrauterine PPFs within 8 months, while Hanlon et al. described improvement of a vacuum extraction-related fracture within 4 months only. These findings support the notion that physiological maturation and outward cranial forces during growth can facilitate fracture resolution.^23,24

Conclusion

In conclusion, the choice between vacuum-assisted and standard neurosurgical approaches should be based on fracture severity, the neonate’s general status, and associated clinical findings. While vacuum-assisted procedures provide a promising, minimally invasive option with a shorter recovery period, traditional surgery is still necessary for severe and complex fractures. Each condition should be evaluated separately, with management options customized accordingly. Nevertheless, this case report contributes to the knowledge and treatment of PPFs of the skull in neonates by providing insights into the possible benefits of non-invasive and relatively simple procedures.

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