![]() A vacuum delivery system with PalmPump (Kiwi OmniCup with Traction Force Indicator VAC-6000MT) is placed overlapping the skull depression to ensure a tight seal between the scalp and the suction cup. In this video, the patient is intubated, under general anesthesia, and positioned supine with the head resting on a gel donut and turned to the left (contralateral to the fracture). Vacuum-assisted elevation of a ping-pong skull fracture in a neonate. The vacuum application may be repeated as needed to attempt elevation of the depressed fracture however, we prefer to limit this to no more than 5 times if no progress has been attained despite achieving a good seal between the scalp and the suction cup ( Fig. Negative pressures are increased sequentially with the PalmPump to a maximum of 500 mm Hg for a maximum of 20–30 seconds at a time or until an audible pop is heard. Hair clipping may be necessary to achieve a good seal between the suction cup and the scalp. We use the vacuum delivery system with PalmPump (Kiwi OmniCup with Traction Force Indicator VAC-6000MT, Clinical Innovations). Patients early in the series were placed under general anesthesia, while patients later in the series underwent monitored anesthesia care (MAC) without intubation. 1–5, 7–17 Herein, we report our experience with vacuum-assisted elevation of ping-pong skull fractures in pediatric patients and evaluate the variables affecting procedural outcomes.Īll procedures were performed in an operating room with a plan to proceed with open elevation of the fracture via burr hole if vacuum-assisted elevation failed. Since 1970, there have been only 16 publications on nonsurgical treatment for the elevation of depressed skull fractures using negative-pressure (suction) application with various devices. There is currently a paucity of data regarding the use of nonsurgical strategies for the elevation of ping-pong skull fractures in pediatric patients. 2, 6 The management of children with ping-pong skull fractures may include observation alone, nonsurgical treatments, or surgical intervention depending on the age, clinical presentation, imaging findings, and cosmetic appearance of the patient. There have been several reports documenting the spontaneous resolution of these fractures however, this can be a slow process (up to 6 months 6) that is riddled with parental anxiety. ![]() In older children, these fractures are commonly related to blunt trauma and falls. 1–5 In the newborn period, this type of fracture can be seen in association with perinatal factors such as cephalopelvic disproportion and obstetrical trauma. A ping-pong fracture is an example of such a fracture and has been compared to green-stick fractures of the long bones. These forces may result in skull depressions that may or may not be associated with an actual fracture, i.e., without loss of bone continuity. T he malleability and plasticity of the pediatric skull make it susceptible to deformation by application of external forces, such as those resulting from intrauterine constraint or trauma. Postprocedure imaging studies revealed no evidence of complications. Two patients required subsequent surgical elevation of their fractures. Successful fracture elevation was attained in 7 of 9 patients. A greater number of sequential vacuum applications was required for patients with a skull thickness greater than 1 mm at the site of depression and for those undergoing treatment more than 72 hours from fracture onset. Negative pressures were increased sequentially to a maximum of 500 mm Hg. The Kiwi OmniCup vacuum delivery system was used in all cases. The time from fracture to intervention ranged from 7 hours to 8 days. Bone thickness ranged from 0.6 to 1.8 mm. Skull depressions ranged from 23 to 62 mm in diameter and from 4 to 14 mm in depth. All fractures involved the parietal bone. All fractures were deemed severe enough to require elevation by the treating neurosurgeon. All patients had normal neurological examination findings and no evidence of intracranial hemorrhage. Modes of injury included birth-related trauma, falls, and blunt trauma. Four neonates and 5 infants underwent vacuum-assisted elevation of moderate to severe ping-pong skull fractures during the study period.
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