EXTRACRANIAL
HEMORRHAGE AND SKULL FRACTURES IN THE NEWBORN
Modern obstetric practice has decreased the incidence of trauma to the neonate that is clearly associated with primiparity, large infant size, difficult or breech delivery, and use of forceps.
Caput succedaneum, an edematous swelling that may be hemorrhagic,
is seen in vaginal deliveries. It may transilluminate, is soft, pits, is
usually at the vertex over suture lines, and resolves rapidly.
Subgaleal hemorrhage, which usually results from shearing forces
tearing veins, occurs between the galea aponeurotica
and the periosteum of the skull. It spreads widely, crosses suture lines, may
dissect over the forehead and even into an orbit, and may take weeks to resolve.
Neonates should be followed closely for symptomatic anemia.
Cephalohematoma is a subperiosteal hemorrhage associated with a
linear skull fracture in about 5% of cases. It may result from the use of
forceps, can also be related to mechanical factors in the pelvis and the
shearing forces of active labor, and palpates like a depressed fracture.
Rarely, these hematomas calcify instead of resorbing. Most calcified hematomas
will spontaneously resolve as the skull grows and incorporates the area.
Skull Fractures. Neonatal skull fractures may be classified as
linear, depressed, or occipital osteodiastasis. Linear fracture may be
associated with cephalohematoma or, in
traumatic deliveries, with epidural and subdural hemorrhage. Most heal without
complication. Rarely, they become diastatic and are associated with a
leptomeningeal cyst due to associated dural and meningeal tears that enlarge
with brain growth.
Depressed (“ping-pong”) fractures
are of little clinical
significance. Most are associated with the use of forceps, but some are related
to intrauterine trauma against pelvic prominences in automobile accidents and
falls, and also in active labor. Surgical elevation may be required and often
can be performed with minimally invasive techniques.
Occipital osteodiastasis is seen in breech deliveries. The associated
dural sinuses may be ruptured, causing a subdural hemorrhage of the posterior
fossa. Surgical drainage is rarely necessary.
