A Growing Skull Fracture
Radiology Cases in Pediatric Emergency Medicine
Volume 7, Case 2
Rachel O. Newton-Weaver, MD
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     This is a 10-month-old male who sustained an 
unwitnessed fall off a patio deck.  The height of the fall
was estimated at 2-3 meters.  He landed on a concrete 
surface.  Relatives were nearby and immediately ran to 
the screaming child.  There was no reported vomiting or 
seizure activity.
     On physical examination he was noted to be sleepy 
but easily arousable.  There was echymosis and an 
abrasion over the right periorbital area.  A 7 by 4 by 1 
cm hematoma was palpated over the right parietal 
region.  No Battle's sign was present.  His pupils were 
equal and reactive to light and extraocular movements 
were intact.  Tympanic membranes were intact without 
hemotympanum.  He had no areas of tenderness, 
swelling, bruising or deformity over his trunk and 
     A CT scan of his head was performed.

View his CT scan.

     This CT scan shows an elevated right parietal skull 
fracture with a floating fracture fragment, subarachnoid 
hemorrhage, hemorrhagic contusion of the right parietal 
and occipital lobes and a right parietal subdural 
hematoma.  He was hospitalized and treated 
conservatively with a good recovery.
     Three months after the fall he is now noted to have 
a palpable right parietal skull fracture defect with a 1 
cm "gap" in the bone.  No palpable, pulsatile masses 
are noted.  On clinical exam, he does not have any 
neurologic defects.  A skull series is ordered.

View his skull films.

     These are his left and right lateral views of his skull 
which show a large "gap" with smooth edges consistent 
with a growing skull fracture over his right parietal skull 
region.  A follow up CT scan of his head is ordered.

View his follow up CT scan.

     These CT scan images demonstrate the persisting 
skull defect and an underlying encephalomalacic cystic 
defect which is consistent with a leptomeningeal cyst.
     He underwent a right craniotomy with dural repair.

     Simple skull fractures usually heal without incident 
within a few weeks.  One potential complication is a 
"growing skull fracture".  Although most commonly 
known as a growing skull fracture, it is also referred to 
as a leptomeningeal cyst or posttraumatic meningocele 
(1).  The essential features of this condition are a skull 
fracture in infancy or early childhood, a dural tear at the 
time of fracture, brain injury beneath the fracture and 
subsequent enlargement of the fracture to form a 
cranial defect (2).
     The incidence of growing skull fractures is estimated 
at 1% among skull fractures in children.  Growing skull 
fractures occur during the first 3 years of life and almost 
never after eight years of life (3).  This is due to the 
rapid increases in brain growth seen only in infancy. 
     A dural laceration is an essential component of a 
growing skull fracture.  The development of a growing 
skull fracture requires a fracture severe enough to 
include a tear in the underlying dura and an outward 
driving force such as a normally growing brain or 
hydrocephalus (1).  Continued pulsation of the brain 
and arachnoid is thought to enlarge the fracture over 
time (4) and herniation of the cerebral tissue or 
subarachnoid fluid through the fracture line may occur.  
A leptomeningeal cyst represents an invagination and 
entrapment of arachnoid into a diastatic fracture with an 
associated dural tear (5). This prevents healing of the 
fracture margins, can cause expansion of the fracture 
and is a palpable mass on physical exam. 
     Linear fractures most commonly are associated with 
growing skull fractures while depressed fractures are 
not.  A fracture with a diastasis (separation) of more 
than 4 mm may be considered at risk of developing a 
growing fracture (3).  Beneath the lesions of skull and 
dura matter there is local brain injury which is a 
constant feature of this syndrome (2) and on acute 
imaging studies there is usually an indication of a 
cortical injury immediately beneath the fracture (1).
     A growing skull fracture presents as a progressively 
enlarging pulsatile mass or an enlarging and sunken 
palpable cranial defect (6).  It may enlarge over
months and occur months after the initial skull fracture.  
Neurological complications related to growing skull 
fractures include seizures (often intractable), 
hemiparesis and psychomotor retardation (3).  The 
majority of cases have shown progressively worsening 
neurologic deficits over time (6).  Therefore, it is 
important to examine children with skull fractures 4-6 
weeks post injury to ensure adequate healing at the 
site of the initial fracture. 
     The most common location for the development of a 
growing fracture is the parietal bone, although it can 
occur anywhere, including the skull base (1).  Skull 
radiographs taken at the time of the initial injury will 
universally demonstrate a diastatic fracture, with the 
edges separated by more than 3mm (6). 
     Computed tomography is helpful in identifying 
underlying intracranial pathology.  Imaging done at the 
time of trauma may show a hemorrhagic contusion or 
subarachnoid or extraparenchymal  hemorrhage (3).   
CT scan done months after the injury may also 
demonstrate unilateral ventricular enlargement and a 
shift toward the skull defect (6).
     Early surgical correction is recommended due to the 
risk of neurological complications (seizures, 
hemiparesis).  There is no indication that the condition 
ever improves spontaneously (6).  Intractable seizures 
in association with a growing skull fracture often 
respond to surgical correction.  Principles of surgery 
include reconstruction of the dura, reconstruction of the 
skull and excision of excessive scalp tissue (4). 

     1.  Luerssen TG.  Skull fractures after closed head 
injury.  In:  Albright AL, Pollack IF, Adelson PD (eds).  
Principles and Practice of Pediatric Neurosurgery.  
Thieme, New York, 1999, pp821-823.
     2.  Lende RA, Erickson TC.  Growing skull fractures 
of childhood.  Journal of Neurosurgery 
     3.  Tomita T.  Growing skull fractures of childhood.  
In:  Wilkins RH, Rengachary SS (eds).  Neurosurgery.  
McGraw Hill, New York, 1996, pp2757-2761.
     4.  Raffel L, Litofsky NS.  Skull fractures.  In:  Cheek 
WR (ed).  Pediatric Neurosurgery.  WB Saunders 
Company, Philadelphia, 1994, p258.
     5.  Beckett WW, Ball WS.  Craniocerebral trauma.  
In:  Ball WS (ed).  Pediatric Neuroradiology. 
Lippincott-Raven, Philadelphia, 1997, pp454-455.
     6.  Luerssen TG, Eisenberg HM, Levin HS.  Late 
complications of head injury.  In:  Cheek WR (ed).  
Pediatric Neurosurgery.  WB Saunders Company, 
Philadelphia, 1994, pp297-298.

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Web Page Author:
Loren Yamamoto, MD, MPH
Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine