The Paediatric Skull - Fracture or suture

Congress:

ECR 2020

Poster Number:

C-14334

Type:

Educational Exhibit

Keywords:

Education and training, Congenital, Acute, Perception image, Normal variants, Education, CT, Conventional radiography, Trauma, Bones, Anatomy, Paediatric, Not applicable

Authors:

C. Y. Ng, S. H. M. Y. Y. Alqarooni, C. M. Leung, J. H. Fong, J. Foster; Plymouth/UK

DOI:

10.26044/ecr2020/C-14334

DOI-Link:

https://dx.doi.org/10.26044/ecr2020/C-14334

Fig. 1: 3D volume rendered CT images and plain radiograph demonstrating the various...

Fig. 2: Axial CT images of the calvarium and base of skull, demonstrating the cranial...

Fig. 3: 3D volume rendered CT and Axial images demonstrating the skull of a 6 month old...

Fig. 7: 3D volume rendered CT image demonstrating bilateral accessory occipital...

$Table 1: Summary table showing characteristic appearances and differences between cranial fractures and sutures.$

Table 1: Summary table showing characteristic appearances and differences between...

$Fig. 10: Axial and 3D volume rendered CT images of a 1.5 years old child who sustained a major trauma, resulting in multiple skull fractures bilaterally.$

Fig. 10: Axial and 3D volume rendered CT images of a 1.5 years old child who sustained a...

Fig. 12: Axial CT image of the same child, demonstrating a left frontal extradural...

Learning objectives

1. To understand the normal anatomy of the paediatric skull and the appearances and locations of various accessory sutures. 2. To identify the characteristic differences between sutures and fractures to aid in diagnosis.

Background

Clinical problem There remains a diagnostic conundrum in distinguishing fractures and sutures especially within the paediatric population. This is due to the numerous developmental calvarium and skull base sutures that occur normally in children, in which themselves have variable appearances and closure periods. Significance? Head trauma in children is a common presentation in the emergency department (children younger than 15 years old make up 33 - 50% of all head injury cases in England and Wales) [1], and is a common cause for morbidity and...

Findings and procedure details

The cranial suturesand normal variants: Large sutures: Coronal suture Sagittal suture Lambdoid suture Squamosal sutures (temporosquamosal and sphenosquamosal sutures) Parietomastoid suture Developmental sutures/syncondroses: Metopic Sphenofrontal Occipitomastoid Innominate Intra-occipital syncondroses Spheno-occipital syncondroses Normal variants: Accessory occipital suture (Mendosal) Accessory parietal suture Persistent occipital suture Wormian bones Closure timeline: Suture/syncondroses Average Time of closure Metopic 3 –9 months** Anterior fontanelle 18 - 24 months Innominate 4 years Mendosal 6 years Sphenosquamosal 6 – 10 years Intra-occipital syncondroses 12 years Sphenofrontal 15 years Occipitomastoid 16 years Spheno-occipital syncondroses...

Conclusion

Questions to ask yourself: Is it unilateral or bilateral and does it appear symmetric or assymetric? Is the line sharp and lucent or is it sclerotic with an interdigitating pattern ? Does the line widen as it approaches a suture? Is there associated diastasis of the suture? Does the line cross the suture ? Are there any other ancillary signs ? eg soft tissue haematoma, intracranial haemorrhage, contusion, sutural incongruity. Can this be an anatomical variant ? (consider location, age of the patient and morphology)

Personal information and conflict of interest

C. Y. Ng; Plymouth/UK - nothing to disclose S. H. M. Y. Y. Alqarooni; Plymouth/UK - nothing to disclose C. M. Leung; Plymouth/UK - nothing to disclose J. H. Fong; Plymouth/UK - nothing to disclose J. Foster; Plymouth/UK - nothing to disclose

References

1. Head injury - NICE CKS. Cks.nice.org.uk. 2016 [cited 5 November 2019]. Available from: https://cks.nice.org.uk/head-injury 2. McGrath A, Taylor R. Pediatric Skull Fractures. Ncbi.nlm.nih.gov. 2019 [cited 1 November 2019]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482218/ 3. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of Missed Cases of Abusive Head Trauma. JAMA. 1999;281(7):621–626. doi:10.1001/jama.281.7.621 4. S. Idriz, J.H Patel, SA. Renani, R. Allan, I. Vlahos. CT of Normal Developmental and Variant Anatomy of the Paediatric Skull: Distinguishing Trauma from Normality. RadioGraphics RSNA. 2015; 35(5). DOI:...