Growing skull fracture: Delayed presentation, surgical management, and review of the literature

Abstract

Background:

Growing skull fracture (GSF), also known as post-traumatic leptomeningeal cyst, is a rare late complication of a linear skull fracture in young children. It requires an underlying dural tear with progressive herniation of arachnoid membrane and/or brain tissue.

Case Description:

We report a 15-month-old child who sustained a right frontoparietal linear skull fracture at 1 month of age and returned 14 months later with a pulsatile scalp swelling and left hemiparesis. Computed tomography showed a wide right frontoparietal diastasis and adjacent ventricular dilatation. At surgery, the 10 × 3 cm defect was densely adherent to the arachnoid and ependymal surface. Adhesiolysis and watertight galeal duraplasty were performed, and the bone flap was replaced. The findings were most consistent with Naimur-Rahman type III GSF. Motor function recovered almost completely by 6 months, while follow-up at 6 and 12 months showed partial closure of the residual osseous gap.

Conclusion:

GSF should be suspected when delayed scalp swelling or neurological deficits follow an infant skull fracture. Selective follow-up of high-risk fractures and timely watertight dural repair can limit progressive morbidity.

INTRODUCTION

Growing skull fracture (GSF) is a rare late complication of pediatric head trauma, with a reported incidence of 0.05–1.6% of childhood skull fractures.[3,4,11] Classic and contemporary series have emphasized its predominantly infantile occurrence and its potential for progressive cranial and neurological morbidity.[2,8] It develops when a dural tear underlies a linear fracture and arachnoid or brain tissue herniates into the fracture, preventing union and progressively widening the bone gap.[6,11]

Most cases occur in infants and present with an enlarging, sometimes pulsatile scalp swelling. Seizures, focal deficits, cranial deformity, or ventricular and porencephalic changes may appear after a delay. Computed tomography (CT) defines the osseous diastasis and major intracranial changes; magnetic resonance imaging (MRI) better delineates the dural tear and herniated tissue when available.[1]

Watertight dural repair is the essential treatment, with cranial reconstruction adapted to the defect, the child’s age, and available resources.[5,10] We report a delayed type III lesion managed in a resource-limited setting and focus on risk-based follow-up and surgical principles.

CASE PRESENTATION

A 15-month-old child presented with a progressive right frontoparietal scalp swelling and left hemiparesis [Figure 1]. At 1 month of age, the child had been struck on the head by a piece of iron, with transient loss of consciousness. Skull radiography showed a linear right frontoparietal fracture. After brief observation at a regional hospital, the child was discharged without targeted neurosurgical follow-up. Fourteen months later, a progressive cranial deformity and pulsatile swelling developed at the impact site, accompanied by the left-sided motor deficit.

Figure 1:

Clinical appearance of the right frontoparietal pulsatile swelling at presentation.

CT of limited quality demonstrated marked widening of the right frontoparietal fracture and dilatation of the adjacent right lateral ventricle. A three-dimensional bone reconstruction confirmed the wide osseous diastasis [Figure 2]. Publication-quality parenchymal-window images could not be retrieved from the archived examination, and MRI was unavailable. The delayed pulsatile swelling and CT findings supported the diagnosis of GSF.

Figure 2:

Preoperative three-dimensional computed tomography reconstruction showing wide right frontoparietal osseous diastasis at the site of impact.

Surgical treatment

Surgery was performed under general anesthesia with the child supine. Through a question-mark incision, the scalp flap was found to be densely adherent to the arachnoid and, in places, to the ependymal surface of the right lateral ventricle.

A right frontoparietal bony defect measuring approximately 10 × 3 cm was exposed [Figure 3]. A bone flap was fashioned, and the dural edges, separated by about 4 cm, were carefully dissected [Figures 4 and 5]. Adhesiolysis was followed by a wide watertight duraplasty using autologous galea, and the bone flap was replaced [Figure 6].

Figure 3:

Intraoperative view of the right frontoparietal bony defect, measuring approximately 10 × 3 cm.

Figure 4:

Intraoperative exposure of the lesion after creation of the bone flap.

Figure 5:

Dural margins separated by approximately 4 cm after adhesiolysis.

Figure 6:

Wide watertight duraplasty using autologous galea.

Outcome

The postoperative course was uneventful. The left hemiparesis gradually improved, with near-complete motor recovery by 6 months. Clinical and imaging follow-up at 6 and 12 months showed partial closure of the residual osseous gap.

DISCUSSION

GSF mainly affects children younger than 3 years. A dural tear permits arachnoid or brain herniation; cerebral pulsations and rapid brain growth then prevent fracture healing and cause progressive diastasis.[6,11] In our patient, the 14-month delay before referral likely explains the dense scalp-arachnoid-ependymal adhesions and the contralateral hemiparesis.

CT usually confirms fracture widening and demonstrates encephalocele, ventricular dilatation, or a porencephalic cavity, whereas MRI better defines the dural and parenchymal abnormalities.[1] MRI and diagnostic-quality parenchymal CT images were unavailable in this case. The ventricular dilatation and operative exposure of the ependymal surface were most consistent with Naim-ur-Rahman type III GSF, in which a porencephalic cavity extends through the skull defect.[7]

The operative priority is watertight dural closure.[5,10] After adhesiolysis, autologous galea provided a low-cost, immediately available graft, and the existing bone flap was replaced. For a large residual defect, split calvarial grafts or particulate bone chips, with or without fibrin sealant, may be considered according to age and local resources.[7,10] In our patient, partial closure at 6 and 12 months supported continued surveillance of the osseous gap.

Because GSF is uncommon, routine specialist and imaging follow-up for every child with an uncomplicated linear fracture may add cost and parental anxiety. A selective strategy is more appropriate. Singh et al. proposed close follow-up when high-risk features are present, including age younger than 5 years with cephalhematoma, fracture diastasis of at least 4 mm, underlying brain contusion, or MRI evidence of a dural tear with brain herniation.[9] Regardless of baseline risk, a new pulsatile swelling, enlarging skull deformity, seizure, or focal deficit warrants urgent reassessment.

Despite the delayed diagnosis, neurological recovery was nearly complete. This case supports early recognition and watertight closure while illustrating that pragmatic autologous reconstruction can be effective where MRI and specialized cranial graft materials are limited. The single-case design and incomplete archival CT quality limit generalization.

CONCLUSION

GSF should be considered when delayed scalp swelling or neurological symptoms develop after an infant skull fracture. High-risk rather than universal follow-up is appropriate. Watertight dural repair remains the key treatment; in delayed type III lesions, careful adhesiolysis and resource-adapted reconstruction can yield good neurological recovery, although residual osseous defects require serial assessment.

Ethical approval:

Institutional Review Board approval was not required for this single-patient case report in accordance with local institutional policy.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. The child’s parents/ legal guardians gave written informed consent for publication of the clinical information and images. The child’s name and initials will not be published, and due efforts will be made to conceal identity; however, anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors used an AI-assisted language model solely for language editing and editorial refinement. All scientific content, interpretations, and conclusions were verified and approved by the authors, who take full responsibility for the final manuscript. No images were generated or manipulated using AI.

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