24例婴幼儿颅骨生长性骨折的早期诊治

目的 探讨儿童颅骨生长性骨折的临床特点和早期诊断及治疗的意义.方法 回顾性分析本院2007年1月至2013年4月收治的24例经手术确诊为婴幼儿颅骨生长性骨折的患儿临床资料.结果 24例患儿均有颅脑外伤史,CT或MRI检查显示脑挫裂伤及脑软化,头颅3D-CT检查显示颅骨骨折.24例患儿均在就诊后16 d内明确诊断并手术治疗,术中均发现硬脑膜破裂,其中22例行硬脑膜修补和颅骨复位固定手术;1例行硬脑膜修补及颅骨修补手术,1例仅行颅骨修补手术;2例合并脑积水,先行V-P手术.随访1个月至6年,颅骨生长良好,无手术并发症.结论 颅骨骨折和硬脑膜破裂是发生生长性骨折的重要因素;头颅3D-CT及MRI检查对婴幼儿生长性骨折的早期诊断有重要价值,一旦确诊应尽早手术治疗;早期硬脑膜修补和颅骨成形治疗可防止产生进一步的脑损害和更大的颅骨缺损.     

Delayed repair of open depressed skull fracture

INTRODUCTION: Elevation and repair of an open depressed skull fracture is often thought of as an emergency procedure. Common indications for emergent elevation of a depressed skull fracture have been dural tear, seizure, gross contamination or mass effect from bone or a sizable underlying intracerebral hematoma. As treatment of head injury moves towards management of cerebral perfusion pressure (CPP) rather than intracranial pressure (ICP), we sought a way to maximize CPP in the initial treatment of head-injured patients with depressed skull fractures that would eventually require surgery by delaying surgery, when possible, until after the initial period of elevated ICP. METHODS: Over a 12-month period, 7 patients (all male, ages 1-15 years) were admitted to our institution with the diagnosis of open depressed skull fracture without significant mass effect requiring urgent decompression. All had significant head trauma with altered mental status and a Glasgow Coma Score of 3-12. Patients were treated with antibiotic prophylaxis (nafcillin, ceftriaxone, metronidazole), seizure prophylaxis (phenytoin) and underwent CPP management in an intensive care unit setting as indicated by intracranial pressure monitoring or clinical assessment. Length of medical management of CPP ranged from 4 to 12 days. Upon stabilization of CPP, patients were operated for repair of their dural, bone and scalp injuries. RESULTS: All 7 patients treated in the above manner suffered no ill effects from their delayed surgery: there was no meningitis, no late seizures, and no cerebrospinal fluid leak. Complications attributable to delay were not present at follow-up ranging from 12 to 24 months. CONCLUSIONS: We have delayed surgery for repair of open depressed skull fractures in order to maximize medical management of CPP in the setting of acute trauma. Among other considerations, the risk of intraoperative hypotension occurring at a time of acutely raised ICP was avoided by this delay. We conclude that there is a role, in this specifically defined subset of head trauma patients, for delayed surgical repair of open depressed skull fractures.     

Complication of linear skull fracture in young children.

The development of a leptomeningeal cyst following an otherwise uncomplicated linear skull fracture in a young child may result in a sizable cranial defect and irreversible neurological deficit months or years later. This complication most often follows parietal fractures but is also seen after occipital fractures or traumatic suture diastases. An underlying dural tear is a prerequisite to its subsequent development. Neurological deficit may be avoided by early diagnosis, surgical excision, dural closure, and cranioplasty. Early diagnosis depends on obtaining a skull roentgenogram four to six months following the original injury in any child where examination of the scalp and skull suggests and underlying expanding fracture.     

Growing skull fracture of the orbital roof. Case report

Growing skull fractures are rare complications of head trauma and very rarely arise in the skull base. The clinical and radiological finding and treatment of a growing fracture of the orbital roof in a 5-year-old boy are reported, and the relevant literature is reviewed. The clinical picture was eyelid swelling. Computed tomography (CT) scan was excellent for demonstrating the bony defect in the orbital roof. Frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Growing skull fracture of the orbital roof should be considered in the differential diagnosis in cases of persistent ocular symptoms. Craniotomy with excision of gliotic brain and granulation tissue, dural repair and cranioplasty is the treatment of choice.     

Treatment of craniosynostosis by distraction osteogenesis

PURPOSE: Craniosynostosis patients treated with one-stage cranioplasty often have bleeding from the dura mater, fluid collection in the extradural space, and poor wound healing due to skin overstretching. To avoid these complications, we began using distraction osteogenesis. To determine the advantages and disadvantages of the procedure, we retrospectively compared distraction osteogenesis with conventional cranioplasty. PATIENTS AND RESULTS: We treated 24 patients with fronto-orbital advancement. Fifteen had one-stage cranioplasty; 9 received distraction osteogenesis. The one-stage operation patients averaged 25.5 months of age at surgery, 289 min of operating time, and 154 ml of intraoperative blood loss. For the distraction group, the average age was 16.6 months, average operating time was 196 min, and average blood loss was 76 ml. CONCLUSIONS: Compared with one-stage cranioplasty patients, distraction osteogenesis patients had significantly less intraoperative bleeding and shorter operating times. The disadvantages of distraction treatment were the need for multiple surgeries, prolonged hospitalization, wound infection, and dislocation of the distraction device.     

儿童颅骨生长性骨折

目的 探讨儿童颅骨生长性骨折(Growing skull fractwre，GSF)的发病机制、诊治方法。方法 对我院1992年1月2002年4月10年间收治的6例GSF患儿的临床资料进行回顾行分析。结果 6例均有明确颅脑损伤病史，平均发病年龄2．99岁，头部包块、颅骨缺损及神经功能障碍等症状常见，颅骨平片见以骨折线为长轴的梭形颅骨缺损，CT检查显示包块为蛛网膜囊肿或脑膨出，术中见硬脑膜缺损大于颅骨缺损；Goldstein分型：Ⅰ型2例，Ⅱ型2例，Ⅲ型2例；GOS5分者3例(2例Ⅰ型和1例Ⅱ型)，4分者2例(Ⅱ型和Ⅲ型各1例)，3分者1例(Ⅲ型)。结论 ①颅骨骨折致硬脑膜破损为GSF发病的病理基础，婴幼儿期颅脑发育、外伤后局部颅内压力增高、骨折缘缺血为发病的重要因素；②GSF患儿颅骨缺损范围与病程不呈正相关，颅脑CT在GSF的诊断方面优于颅骨平片；③GSF一经确诊即应手术治疗，扩大开颅术能显露硬脑膜残缘，严密修补硬脑膜是手术成功的关键，Medepor材料适用于GSF患儿。Goldstein分型对指导预后有一定意义。     

Successful use of rib grafts for cranioplasty in children

Numerous materials are available for use in cranioplasty including bone, plastics and metals. Rib grafts as a construct for cranial reconstruction offer several advantages: autologous bone source, a formable platform, low infection, regeneration at the donor site and high fusion rates. Criticism of rib graft cranioplasty includes scarring and pain at the donor site, irregular contour at the graft site and graft reabsorption. Since 1988, we have performed rib autograft cranioplasty on 13 patients. Seven females and 6 males combined for an average age of 6 years (11 months to 20 years) at the time of surgery. The mean follow-up from surgery is 27 months (2-48 months), with 11 subjects having at least 12 months. The commonest reasons for cranial reconstruction were: post-traumatic calvarial defect (n = 4), defect from previous craniotomy (n = 3), "growing" skull fracture (n = 2), and defect from previous encephalocele closure (n = 2). Mean defect size was 41 cm(2) (8-144 cm(2)) and average number of ribs harvested was 1.75 (1-3). Simple rib cranioplasty had a mean time in the operating room of 6 h and 30 min. No donor site complications were noted (pneumothorax, significant post-operative pain) and no post-operative infections were encountered. Excellent cranial contour was achieved in each of the 11 patients followed for a minimum of 12 months. One subject required staged reconstructive procedures owing to the size of the defect.     

Temporal bone fractures in children: a review with emphasis on long-term sequelae.

A 10-year retrospective study of pediatric basilar skull fractures identified 120 patients with temporal bone fractures, of which 92 had otolaryngologic and audiologic evaluations. The otologic data provide documentation of the nature, common physical findings, complications, and management of these fractures. The prognosis of hearing impairment in children caused by temporal bone fractures is elucidated, as 76 of the 92 patients were available for long-term follow-up. Close interaction between involved services evaluating and treating pediatric trauma cases is mandatory for optimal patient outcome. A literature review of the presentation, complications, and management of pediatric temporal bone fractures is presented.     

Growing fractures of the orbital roof. A report of two cases and a review

Growing fractures rarely arise in the skull base. Only six cases of orbital roof growing fractures were found in the relevant literature. We report two such cases. The first case was a 2-year-old girl who had progressive proptosis for 6 months following a mild head injury 1 year previously. The second case was a 9-year-old girl with a history of injury at the age of 3 months. She developed eye deviation and proptosis for 1 year. Computed tomography scan is excellent for demonstrating bony defects in the orbital roof, while magnetic resonance imaging is more sensitive in showing the intraorbital extension of a leptomeningeal cyst. Both patients were operated successfully and proptosis disappeared postoperatively. The exact pathophysiology of growing fractures is still debated in the literature, but a dural laceration along a fracture line is noted in all cases, and frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Growing fractures of the orbital roof should be suspected if ocular symptoms appear in a child who had sustained a head injury several months or years before.     

The value of MRI in the early diagnosis of growing skull fracture

Growing skull fracture (GSF) is a progressive enlargement of a fracture due to an underlying tear of the dura mater. It is a rare complication of severe head injury mainly reported in young children. Classically, the diagnosis is made during follow-up, late after the original injury, when a palpable skull defect or a bulging mass is discovered clinically. Initial skull radiographs show a diastatic fracture developing later into a large bony defect. CT will show the brain damage which is usually present beneath the fracture. We present the MRI findings of GSF in a series of eight children. All patients initially had a large linear fracture and underlying brain damage on CT. In all cases MRI showed a zone of the same intensity as the brain contusion or cerebrospinal fluid advancing through the bone margins of the fracture to the subcutaneous plane. This finding was interpreted as an indirect sign of the dural tear. Seven patients were operated on with surgical confirmation of GSE MRI can make an early diagnosis of GSF possible so that surgical repair with closure of the dura can be carried out before the dural tear enlarges.Presented at the 32nd Congress of the European Society of Pediatric Radiology, 18–20 May 1995, Utrecht, The Netherlands, and selected for publication by an International Group of the ESPR     

弹性髓内钉在儿童肱骨骨折中的应用

目的 分析弹性髓内钉内固定治疗儿童肱骨骨折的临床疗效.方法 2005年3月至2009年2月作者采用钛制弹性髓内钉内固定治疗儿童肱骨骨折26例.结果 患儿均获随访,随访时间为12～32个月,平均20.4个月.均骨折愈合,骨痂生长良好,邻近关节活动和患肢功能恢复正常,术中1例发生两钉缠绕,术后1例出现感染,1例发生皮肤激...     

Treatment of depressed skull fractures in neonates using percutaneous microscrew elevation

Depressed skull fractures in neonates involve the inward buckling of the skull bones to resemble a cup shape or "ping-pong ball" shape. In the past, several methods have been used to treat these fractures for cosmetic effect, including the use of vacuum extraction. The aim of this study was to demonstrate the use of a novel treatment method for these skull fractures. All patients presented to Hershey Medical Center between May 2007 and March 2010. All underwent treatment of their ping-pong skull fracture using a novel technique of percutaneous screw elevation with self-tapping microscrews (4 or 5 mm) typically used in neurosurgery for cranial plating. Four patients were treated, all between the ages of 2 days and 4 months. Two of the patients were treated under general anesthesia and 2 with local anesthesia only. All patients had good cosmetic results and experienced no adverse events. Percutaneous screw elevation of the ping-pong type, simple depressed skull fracture in neonates is a feasible method of treatment with a low complication rate associated with the procedure and no risk from anesthesia.     

带锁髓内针治疗大龄儿童股骨干骨折

目的 评价带锁髓内针治疗大龄儿童股骨干骨折的疗效.方法 1999年8月至2008年4月,我院收治46例患儿的47侧股骨干骨折采用带锁髓内针治疗,男33例,女13例.平均受伤年龄11岁9个月(8岁9个月～14岁).结果 所有骨折治疗后均获骨性愈合,无畸形愈合和延迟愈合.患侧肢体平均过度生长4.6 mm(-6 mm至14.7 mm),其中3例超过10 mm.没有股骨头缺血坏死的病例.术后平均13个月取出髓内针(7～21个月),术后未发生再骨折和股骨颈骨折.结论 治疗大龄儿童股骨干骨折,带锁髓内针是一种有效而可靠的选择.     

Central skull base lymphoma in children: MR and CT features

BACKGROUND: Central skull base tumours are rare in children. OBJECTIVE: To characterize the imaging features of central skull base lymphoma in children to aid its diagnosis. MATERIALS AND METHODS: The authors reviewed the CT findings (available in three patients) and MR findings (available in four patients) in four patients (three boys, one girl; age 2-12 years) with pathologically proven lymphoma (two with Burkitt lymphoma, two with B-cell lymphoma) involving the central skull base. Tumour location and extent, MRI signal intensities, noncontrast CT attenuation, patterns of enhancement, and changes in adjacent structures were evaluated. RESULTS: All four tumours involved the sphenoid bone. In three patients, the tumour extended to the ethmoid sinus and both cavernous sinuses. All lesions were isointense solid masses on T2-weighted images and showed avid enhancement, except for one lesion with a focal necrosis. All tumours were associated with adjacent dural thickening. Non-contrast CT showed highly attenuating masses and permeative bone destruction in the central skull base. CONCLUSION: Lymphoma involving the central skull base in children is visualized as an isointense mass on T2-weighted MRI with marked contrast enhancement and adjacent dural thickening, and as a highly attenuating mass on noncontrast CT with permeative or erosive bone destruction patterns.     

Eosinophilic granuloma of the skull: a retrospective analysis

BACKGROUND: The authors describe 9 cases of children with eosinophilic granuloma (EG) of the skull and report on their clinical manifestations, treatment, and prognosis. METHOD: Nine consecutive patients were diagnosed as EG of the skull and confirmed pathologically between 1996 and 2005. In the present study, multi- and single-system Langerhans' cell histiocytosis without skull involvement were excluded. Patients with EG of the skull were divided into two groups: (1) those with only a single bone lesion and those with (2) multiple bone lesions. Surgical removal was performed between 2 and 10 years of age (mean, 4.2 years). RESULTS: Eight (88.9%) of the study subjects were found to have a single bone lesion at diagnosis, and 1 had multiple bone lesions. Seven patients had a painless skull mass and 2 patients had a painful skull mass. Total removal was performed in all 9 patients. Eight patients received postoperative chemotherapy or indomethacin as adjuvant therapy. Of the 8 patients who received adjuvant therapy, 4 were treated with indomethacin and the remaining 4 received methotrexate-based chemotherapy. Eight patients did not experience EG recurrence, however, 1 patient developed additional lesions 2 years after surgical excision. CONCLUSIONS: EG of the skull is a clinicopathological entity with a good outcome. However, therapies and prognoses are dependent on age at diagnosis and the number of bony involvements.     

Imaging modalities of craniosynostosis with surgical and pathological correlation

Premature fusion of the sutures of the skull has been extensively analyzed and several diagnostic imaging modalities have been proposed. Radiographic, scintigraphic and computed tomographic features of craniosynostosis have been reported. This study was initiated (a) to determine the value and accuracy of plain skull radiography, skull scintigraphy and cranial CT; and (b) to determine the optimal imaging modality for the evaluation of a clinically suspected craniosynostosis. The study is based on 36 patients with clinical suspicion of craniosynostosis who underwent craniectomy and cranioplasty. One hundred and three sutures were pathologically and/or surgically evaluated. The overall accuracy rate for skull radiography was 89%, skull scintigraphy, 66%, and cranial CT, 94%. Routine skull series are adequate in the majority of cases of craniosynostosis. Skull scintigraphy is less accurate, more costly, and has a limited role in the evaluation of craniosynostosis. Cranial CT should be reserved for those cases in which the findings in the routine skull series are not clearly positive or negative, or in cases of more complex cranofacial anomalies.     

儿童四肢长骨病理性骨折手术治疗60例

目的 总结儿童四肢长骨病理性骨折的手术治疗经验,探讨提高临床诊断和治疗水平的方法.方法 2005年1月至2010年3月作者收治长骨病理性骨折患儿74例,其中60例采用手术治疗,在确诊原发疾病的同时,给予病灶彻底清除及植骨,并对骨折进行一期内固定处理.患儿出现患肢疼痛等症状的时间为1 d至2年,出现病理性骨折的时间为2 ...     

Midfacial fractures in children.

The purpose of the study was to present a modern classification and discuss the treatment of midfacial fractures in children. From the beginning of 1 January 1998 to 31 October 2000, 147 children were treated for different craniofacial fractures. Among them 28 patients (19 %) had extensive midfacial fractures complicated by impaired vision and/or CNS dysfunction and were treated surgically. The fractures were divided into: zygomatico-orbital (1 pt) and zygomatico-orbito-maxillary (5 pts), isolated orbital wall fractures (14 pts) and naso-orbital dislocations (2 pts), upper facial portion dislocations (2 pts) and fronto-naso-orbital (2 pts) or cranio-orbital fractures (2 pts). Clinical examination revealed mainly dysfunction of facial morphology and aesthetics (enophthalmos, telecanthus), CSF leakage, impairment of vision and restricted eyeball movements. Ophthalmological, neurological and radiological (Waters view, CT, NMR) examinations were performed in all cases. The treatment consisted of bone repositioning, reconstruction with autologous bone grafts and three-dimensional stabilisation using titanium plates. Twenty-three pts were operated on before and 5 pts after 7th day after trauma. The restoration of normal facial morphology was achieved in 26 patients. In 2 cases it was impossible because of the destruction of soft tissue and an extremely extensive bony trauma. Better reposition of bony fragments, prompt healing and better final results were achieved in patients operated before day 7 after trauma. Achieving good results in midfacial fractures requires prompt and adequate treatment and a multidisciplinary (paediatric, maxillofacial, plastic surgeons, neurosurgeon, ophthalmologist) team.     

Pavlik挽具有限制动治疗新生儿股骨干骨折

目的探讨Pavlik挽具有限制动治疗新生儿股骨干骨折的临床疗效。方法 2005年1月-2010年1月,应用Pavlik挽具有限制动治疗新生儿股骨干骨折47例。其中男26例,女21例;左侧16例,右侧31例。臀产位13例,剖宫产29例,正常分娩5例。治疗时年龄12 h～23 d。骨折发生于股骨干中上1/3段38例,中1/3段骨折9例;斜形或螺旋形33例,横行骨折14例。大腿外观有明显向外成角及重叠缩短畸形。成角移位平均45°(22°～80°),短缩移位平均1.0 cm(0.5～2.0 cm)。患儿下肢足趾血运好,无其他合并伤。治疗采用Pavlik挽具,双膝屈曲、双侧髋屈曲外展有限制动。定期随访复查X线片及适时调整挽具。结果 Pavlik挽具应用最短3周,最长6周,平均4周。X线片示骨折线模糊,连续性骨痂形成后去除Pavlik挽具,并定期随访至学步期。平均随访20个月(8个月～4 a),47例骨折均一期治愈,患侧肢体外形好,无短缩,无跛行步态。结论 Pavlik挽具有限制动治疗新生儿股骨干骨折方便简捷、安全可靠、疗效好、并发症少,不需要住院或住院时间短。     

关节镜下复位固定治疗儿童胫骨髁间隆突骨折

目的 探讨关节镜下钢丝固定治疗Ⅱ、Ⅲ型儿童胫骨髁间隆突撕脱性骨折的疗效及其影响因素.方法 手法复位失败的Ⅱ、Ⅲ型胫骨髁间隆突撕脱性骨折患儿12例,行关节镜下复位、钢丝内固定治疗.平均随访时间24.4个月(12～32个月),Lachnmn试验、轴移试验评价膝关节稳定性,Lysholm评分及Tegner分级评价膝关节功能,术后X线评价骨折愈合情况.结果 12例骨折均获得满意的复位,术后3个月内骨性愈合,X线检查未见骺板早闭现象.未见关节纤维化内固定松动感染等严重并发症发生.Lysholm膝关节功能评分96.7±2.2分,Tegner评分术前术后分别为2.8±1.1和7.5±0.9.结论 关节镜下钢丝固定是治疗Ⅱ、Ⅲ型儿童胫骨髁间隆突撕脱性骨折的有效方法,可有效重建膝关节的稳定,改善膝关节功能.