INTRODUCTION

Approximately 7% to 10% of pediatric patients admitted with head injuries are diagnosed with depressed skull fractures [1–4]. Depressed skull fractures can lead to serious complications, including dural lacerations, brain parenchymal injury, intracranial hemorrhage, posttraumatic seizures, and infections. Although the incidence of depressed skull fractures, commonly known as "ping-pong fractures," is relatively low in neonates and infants, at about 1 to 2.5 cases per 10,000 individuals, various nonsurgical and conservative treatment methods have been proposed. These techniques include digital pressure [5], the use of a vacuum extractor [6–8], percutaneous elevation with microscrews, and traditional craniotomy methods [3,6,9–12]. However, neurosurgeons may encounter difficulties mastering these less familiar tools, potentially leading to unsuccessful treatment [8,10,13].

Younger children have thinner skulls than adults [14]. Additionally, they are more likely to experience greenstick fractures, thus increasing the possibility of depressed skull fractures. Even in the absence of notable neurological symptoms or open wounds, neurosurgeons often experience hesitation in deciding to carry out a surgical intervention for significant depressed fractures, particularly when performed for cosmetic reasons. In cases involving severe depression without acute symptoms, surgery may still be necessary to prevent potential neurological complications during development and for aesthetic improvement. Another reason for hesitation is that conventional craniotomy methods may result in cosmetic dissatisfaction due to visible gaps between bones. This report describes our institution's experience with minimally invasive reduction surgery for pediatric depressed skull fractures.

CASE REPORT

A female pediatric patient aged 5 years and 2 months sustained injuries as a passenger in a van involved in a rear-end collision with a trailer. She was initially taken to a nearby local hospital and transferred to our hospital approximately 3 hours later due to persistent symptoms of headache and increased drowsiness. On admission, the patient presented mild drowsiness and headache but exhibited no specific neurological deficits. Her vital signs were stable, and no external wounds were evident; however, edema was observed in the right parietal region.

A 3-mm-thick computed tomography (CT) scan revealed a depressed fracture of the right parietal bone, 45 mm in diameter and 6 mm in depth, along with a scant amount of epidural hemorrhage. Detailed visualization through a three-dimensional (3D) reconstruction CT scan with 0.625-mm slice thickness clearly delineated the depressed skull fracture's configuration (Fig. 1). The fracture appeared generally round with internally located H-shaped multiple linear fractures. Given concerns regarding potential epidural hemorrhage progression and neurological deterioration, the patient was admitted to the intensive care unit (ICU) for close monitoring. No changes in her neurological status were observed during her ICU stay. Follow-up CT on the second day of hospitalization showed no increase in hematoma.

On the third day of hospitalization, the patient underwent elective surgery to reduce her depressed skull fracture. Under general anesthesia, endotracheal intubation and routine draping were performed. Anticipating potential difficulties or failure with the new reduction technique, an incision was made as a precautionary measure. Additionally, the possibility of increased epidural hematoma or other unforeseen complications was considered. The patient was positioned supine with her head rotated approximately 40° to the left. A linear incision approximately 7 cm in length was made to expose the depressed fracture, as confirmed by CT. Under 3D CT guidance, two burr holes were drilled at the intersection points of the internal H-shaped fracture lines, chosen for their optimal positioning to maximize mechanical advantage during elevation and ensure symmetrical correction of the depressed fragment. The burr holes were created using a 2-mm burr drill, and two Adson blunt dissecting hooks (NL2410, V. Muller). The two inserted hooks were carefully elevated simultaneously, oriented perpendicular to the skull curvature at their insertion points to achieve effective and controlled reduction. While the surgeon applied vertical force to elevate the depressed bone using the hooks, an assistant stabilized the patient's head, providing countertraction to maintain control throughout the procedure (Fig. 2). The depressed fracture was successfully reduced, confirmed by a distinct clicking sound and the release of tactile resistance, with immediate visual evidence of correction. Postoperative CT imaging confirmed successful reduction and showed no signs of increased hematoma, cerebrospinal fluid leakage, or other intracranial abnormalities. Surgical draping began at 9:55 ᴀᴍ, the skin incision at 10:10 ᴀᴍ, and the entire procedure, including reduction and closure, concluded by 10:40 ᴀᴍ, totaling approximately 30 minutes.

After surgery, the patient's condition remained stable, and she was transferred to a general ward for postoperative care. A CT scan performed 7 days postoperatively showed no specific complications. On postoperative day 8, a 3D CT scan was conducted, confirming that the reduction of the fracture remained satisfactory (Fig. 3). The patient was discharged after 16 days of hospitalization. At an outpatient visit 36 days after injury, the patient remained asymptomatic, and a final follow-up CT scan verified that the reduced skull fracture was stable, without evidence of increased hematoma or other intracranial abnormalities. Given the patient's absence of neurological symptoms, foreign nationality, and the practical limitations involved, long-term follow-up was limited. Additionally, magnetic resonance imaging (MRI) was not performed due to the absence of neurological deterioration and the requirement for sedation in pediatric patients.

Ethics statement

This study was approved by the Institutional Review Board of Pusan National University Hospital as a retrospective investigator-initiated trial (No. 2401-017-135). The need for informed consent was waived due to the retrospective nature of the study.

DISCUSSION

As previously noted, approximately 10% of pediatric patients admitted with head trauma have depressed skull fractures [1–4]. Among pediatric skull fractures, depressed fractures specifically account for 15% to 25% [1–4,11]. The causes of injuries vary depending on socioeconomic status, cultural factors, and age [4], with traffic accidents predominating in industrialized nations [4,12,14,15]. Choux [1] categorized depressed skull fractures into three types based on radiological features: true depressed fractures involving the cranial vault, flat depressed fractures with complete bone fragment separation, and ping-pong ball fractures characterized by greenstick-type localized depressions. Typically, conservative treatment is recommended when fractures do not involve intracranial hematoma and the depth is less than skull thickness. Surgical intervention is advised for compound fractures, infections, intracranial hematomas, or cosmetic improvement [4,14]. de Paul Djientcheu et al. [6] reported success with vacuum extractors in patients aged from 3 months to 17 years; however, such devices can cause pain, incomplete reductions, and cephalohematoma formation during the procedure.

In the present case, the decision to employ this surgical technique was based on preoperative 3D CT imaging, which indicated that minimally invasive reduction would be feasible. Conventional craniotomy provides advantages such as a clear surgical field, immediate confirmation of fracture reduction, and effective intraoperative bleeding control; however, it frequently results in cosmetic drawbacks, particularly gaps between bone fragments, which we aimed to avoid. Conversely, noninvasive methods, while beneficial cosmetically and offering shorter hospital stays and recovery periods, have limitations including a higher risk of incomplete fracture reduction, the inability to confirm outcomes in real-time, and inadequate preparation for potential intraoperative bleeding. Additionally, these techniques are generally more suitable for neonates due to their highly pliable skulls, making them less appropriate for our 5-year-old patient. Thus, we considered our technique a balanced approach, combining the benefits of conventional craniotomy and noninvasive methods, ensuring surgical precision and cosmetic advantages while minimizing invasiveness. This rationale guided our decision to proceed with this technique.

We successfully executed a novel minimally invasive reduction surgery on a pediatric patient with a depressed skull fracture who exhibited no neurological symptoms. Our technique required only two 2-mm burr holes and avoided conventional craniotomy entirely. No additional intracranial hemorrhage or neurological complications were observed. In cases involving horizontal and vertical fracture lines, selecting intersection points for the burr holes is expected to yield greater success. Utilizing 3D reconstructed CT significantly aids in accurately visualizing and planning the reduction. The reduction achieved was satisfactory both structurally and cosmetically, with no gaps between the bone fragments, which is a favorable contrast to traditional postcraniotomy cranioplasty procedures. Because the method was minimally invasive, the patient experienced minimal pain, and the hospitalization duration and medical costs were reduced.

We utilized Adson blunt dissecting hooks, tools already familiar to neurosurgeons, thus making the procedure technically straightforward. For fractures with a larger diameter, hooks with extended tips should be considered. In future applications, employing navigation systems for precise targeting of burr hole sites with minimal incisions under local anesthesia may further improve outcomes. Although the concept of using blunt hooks for fracture reduction may not be entirely new, our technique specifically emphasizes completely avoiding conventional craniotomy through a truly minimally invasive approach. High-resolution 3D CT imaging is central to our strategy, enabling feasibility assessment and precise anatomical localization for successful fracture reduction.

For pediatric patients with depressed skull fractures who lack neurological symptoms, we recommend our minimally invasive reduction technique over routine observation or conventional craniotomy. Precise visualization of fracture morphology using 3D reconstructed CT imaging is essential to enhance the likelihood of successful reduction.

A limitation of this report is the lack of long-term follow-up, due to the patient's foreign nationality, making extended observation and MRI evaluation at 6 months to 1 year unfeasible. To clearly establish indications and contraindications for this minimally invasive approach, additional case accumulation and systematic long-term radiological evaluations, including MRI findings, are essential.

We acknowledge the importance of validating the reproducibility and generalizability of this surgical technique. Future plans include systematically collecting more cases treated with this method and thoroughly evaluating long-term outcomes, encompassing both radiological and cosmetic results, to support broader adoption of this minimally invasive approach.

ARTICLE INFORMATION

Author contributions

Conceptualization: HJC, MJH; Investigation: SHY, BCK; Methodology: SHY; Project administration: HJC; Writing–original draft: MJH; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Computed tomography (CT) scans. (A, B) A depressed skull fracture with a diameter of 45 mm and a depth of 6 mm was confirmed. (C) A clear visualization of the H-shaped depressed skull fracture was achieved through three-dimensional reconstruction of the CT scan.

Fig. 2.

A linear incision was made to expose the depressed skull fracture, revealing an internal H-shaped fracture pattern. Two burr holes, each 2 mm in diameter, were drilled at the intersection points of the internal horizontal and vertical fractures. Adson blunt dissecting hooks were inserted into each burr hole. While the assistant firmly stabilized the patient’s head, simultaneous elevation with the hooks successfully and immediately reduced the fracture.

Fig. 3.

A computed tomography scan performed on postoperative day 8 demonstrated two 2-mm burr holes and confirmed a smooth and stable reduction of the previously depressed area compared to the preoperative condition.

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