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Elevation of depressed (pond) fracture in infant using a vacuum-assisted device: Technical note

 Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India

Date of Submission23-Jun-2021
Date of Acceptance19-Sep-2021
Date of Web Publication30-Jan-2023

Correspondence Address:
Nishanth Sadashiva,
Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), No.29, Hosur Rd, Ayappa Garden, Adugodi, Bengaluru 560029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_137_21



Introduction: Pond fracture also called ping-pong fracture in children is caused due to direct impact on the skull. It is rare and many types of treatment modalities have been described. In this report, we describe a makeshift vacuum-assisted device to elevate the fracture, which is both cost-effective and efficient. Case presentation: A 5-month-old infant was brought to the emergency department with a history of fall of heavy object on the head resulting in pond fracture over the left parietal area and an episode of focal motor seizures. After ruling out an intracranial injury with a computer tomogram, we elevated the depressed fracture by a makeshift vacuum suction device using a plastic funnel connected to vacuum chamber. Post-procedure child had one episode of focal seizure and was discharged after a brief period of observation. Conclusion: Plastic funnel vacuum suction can be effectively used to elevate the Pond fractures in infants with appropriate precautions.

Keywords: Depressed fracture, ping-pong fracture, pond fracture, vacuum device

How to cite this URL:
Pateria V, Sadashiva N, Konar S, Devi BI, Rewatkar A. Elevation of depressed (pond) fracture in infant using a vacuum-assisted device: Technical note. J Pediatr Neurosci [Epub ahead of print] [cited 2023 Dec 5]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=368798

   Introduction Top

Infantile depressed skull fracture is a neurosurgical emergency. It can present a widespread spectrum from mere cosmetic deformity to hemiparesis. Infantile depressed fracture is also known as ping-pong fracture or pond fracture with inward buckling of the bone surface without loss of bone continuity (similar to the “green-stick” fracture of the long bones of children).[1] It is a rare entity to its description in about 4–10 in 10,000 infants.[2] The most common cause of depressed fractures is direct trauma from bumps or falls in older children. There have been many reports regarding various modes of treatment of such fractures from watchful observation to surgical elevation. One of the least invasive and effective but less commonly used is the use of vacuum-assisted device. With this technique, the results can be astonishing, avoiding the need for craniotomy, or burr hole.

   Case Presentation Top

A 5-month-old male baby-boy was brought by his parents to the emergency department with complaints of depression in the scalp and some jerky movement in the right upper limb after fall of a heavy object on the head which had happened 70 h before presentation. On examination, the child was active alert and moving all four limbs spontaneously feeding intermittently and crying consolable. There was a visible depression in the left parietal bone measuring 4 cm × 3 cm with intact overlying skin. [Figure 1] After initial care, a computer tomogram (CT) brain was performed to rule out intracranial injury, which was suggestive of left parietal depressed fracture, measuring 4.1 cm × 3.2 cm × 1.1 cm with linear undisplaced fracture extending posteriorly [Figure 1].
Figure 1: (A) Picture of patient’s parietal area with a depression caused by a pond fracture. (B) Computer tomogram (CT) axial view with a depressed fracture without any intracranial hematoma. (C and D) Surface-shaded display of the CT showing superior and lateral view of depressed fracture with a lineal fracture extending posteriorly

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   Reduction Procedure Top

After informed consent, child was taken in minor OT. With the use of our indigenous device which is made just from the settings available in any neurosurgical emergency department, we were successful in elevating the ping-pong depressed fracture. As shown in [Figure 2], we devised a “Plastic funnel Vacuum device” in our emergency setting. There are three components of this device: the vacuum chamber, with an adjustable valve; the connector; and the plastic funnel. Micropore plasters were applied around the lip of funnel to prevent leak. The technique was to create fixed suction pressure, within a range of (0.3–0.5 kg/cm2).[3] After applying funnel device over and around the depressed fracture, vacuum pressure was created and fixed at 50 mbar (0.05 kg/cm2). Funnel was removed after about 20 s when a click was felt. The suction effect around the area of depressed fracture caused the fracture to get elevated and hence leading to its reduction [Figure 2].
Figure 2: (A) Plastic funnel with micropore plasters applied to the lips. (B) Wall suction with vacuum suction pressure readings. (C) With application of the vacuum device over the patients head. (D) After removal of the vacuum device with reduction of depressed fracture

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   Post Procedure Care and Imagines Top

Child was kept in close observation and under the mother's care. Breastfeeding was continued. Post-procedure delayed imaging was performed to rule out any underlying injury. The CT brain with 3D surface-shaded display (SSD) showed a good reduction of the fracture [Figure 3]. One episode of focal onset motor seizures without impaired awareness was noted on the same day but controlled on anti-epileptics dose modification. After two seizures free day child was discharged in satisfactory condition.
Figure 3: (A and B) Post-procedure axial and coronal images of CT with total reduction of depressed fracture with images. (C and D) Surface-shaded display of CT with elevated fracture and the residual linear undisplaced fracture posteriorly

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   Discussion Top

The pond fracture is a visible deformity that leads to a great concern in parents regarding underlying brain injury and its consequences. The management of pond fracture is described in various studies from conservative treatment to surgical intervention. No clear-cut criteria regarding management have been defined. In the past, the classic recommendation for a simple depressed skull fracture was to surgically elevate it based on concerns regarding cosmetic effect, possible underlying pathological features, and epileptogenicity.[3] Several subsequent investigations have suggested, however, that surgical management of such an injury may not be mandatory. Spontaneous recovery, although rare, has been occasionally reported. Authors of a review have reported that spontaneous elevation of congenital depressed skull fractures occurred within 1 day to 6 months of age.[4] Raynor and Parsa[5] shown a nonsurgical method by elevating depressed fracture in 9-month-old infant after applying graded pressure over edges of depressed fracture.

After demonstration of elevating a skull depression by using a breast pump by Shrager. Several authors have found the obstetrical vacuum extractor to be more effective because of its greater suction power.[6],[7],[8],[9] The application of vacuum extraction seems to have age limitations. Most reports of vacuum reduction for simple skull depression featured newborns and infants, and the oldest age was 18 months.[10] In vacuum-assisted procedure, many technical factors need due consideration. In our setup controlled suction apparatus attached with respective size funnel device preferably transparent is the best device to conduct the procedure because it provides patent tubing unlikely to collapse during the application of suction with precise control of pressure. Furthermore, the transparent funnel should be able to cover the entire depression and to attach tightly to the patient’s head without the likelihood of air leakage between the patient’s skin and the periphery of the suctioning device. After feeling of click or pop up sound, device should be removed as soon as possible to prevent superficial injury.

Jennett et al.[11] described that there was no observed increase in post-traumatic seizure among patients whose simple depressed skull fractures were treated non-surgically. Steinbok et al.[9] further reported that there was no difference in outcome between children with simple depressed fractures treated surgically and non-surgically in the aspects of seizure occurrence, neurological dysfunction, or overall cosmetic picture. They thus suggested that the nonsurgical modality be the standard treatment regimen for simple depressed fractures among pediatric patients. No criteria still exist regarding ideal suction pressure. From the literature, a reasonable choice would be a negative pressure of approximately 0.2 kg/cm2 for a 1-kg premature baby[7] and 0.4–0.6 kg/cm2 for a full-term newborn.[7],[12],[13] For older patients, a negative pressure of 0.8 kg/cm2 was sufficient for either a 5.5-month-old[14] or an 18-month-old infant.[10]

In acute injury and emergency setup vacuum-assisted elevation is a viable option without substantial risk. For older children with simple depressed skull fractures, conservative management remains the standard regimen, and surgical elevation would be considered only for individuals with a significant cosmetic defect, because vacuum extraction is not feasible for them.

   Conclusion Top

Vacuum-assisted elevation seems to be a quick, easily reproducible, controlled procedure. It can be conducted in a minimal-resources setup with less procedure-related adverse effects in emergency settings with minimal cost. More studies are needed for prescribing proper guidelines for depressed fracture in infants and use of designated vacuum-assisted devices in its management.

Ethical policy and institutional review board statement

Ethical approval was not required for this study in accordance with national guidelines.

Data availability statement

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Authors’ contribution

Vibhor Pateria was involved in conceptualization, methodology, validation, investigation, and writing––original draft preparation. Nishanth Sadashiva was involved in conceptualization, validation, writing––original draft preparation, visualization, and supervision. Subhas Konar was involved in methodology, validation, investigation, and writing––editing. Bhagavatula Indira Devi was involved in resources, writing––review and editing, and supervision. Ajinkya Rewatkar was involved in investigation, writing––original draft preparation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

   References Top

Matson DD. Neurosurgery of infancy and childhood. 2n ed. Springfield, IL: Charles C. Thomas; 1969.  Back to cited text no. 1
Nadas S, Reinberg O. Obstetric fractures. Eur J Pediatr Surg 1992;2:165-8.  Back to cited text no. 2
Hung KL, Liao HT, Huang JS. Rational management of simple depressed skull fractures in infants. J Neurosurg 2005;103: 69-72.  Back to cited text no. 3
Strong TH Jr, Feldman DB, Cooke JK, Greenspoon JS, Barton L. Congenital depression of the fetal skull. Obstet Gynecol Surv 1990;45:284-9.  Back to cited text no. 4
Raynor R, Parsa M. Nonsurgical elevation of depressed skull fracture in an infant. J Pediatr 1968;72:262-4.  Back to cited text no. 5
Ross G. Spontaneous elevation of a depressed skull fracture in an infant: case report. J Neurosurg 1975;42:726-7.  Back to cited text no. 6
Saunders BS, Lazoritz S, McArtor RD, Marshall P, Bason WM. Depressed skull fracture in the neonate: report of three cases. J Neurosurg 1979;50:512-4.  Back to cited text no. 7
Schrager GO. Elevation of depressed skull fracture with a breast pump. J Pediatr 1970;77:300-1.  Back to cited text no. 8
Steinbok P, Flodmark O, Martens D, Germann ET. Management of simple depressed skull fractures in children. J Neurosurg 1987;66:506-10.  Back to cited text no. 9
Paul MA, Fahner T. Closed depressed skull fracture in childhood reduced with suction cup method: case report. J Trauma 1991;31:1551-2.  Back to cited text no. 10
Jennett B, Miller JD, Braakman R. Epilepsy after monmissile depressed skull fracture. J Neurosurg 1974;41: 208-16.  Back to cited text no. 11
Ben-Ari Y, Merlob P, Hirsch M, Reisner SH. Congenital depression of the neonatal skull. Eur J Obstet Gynecol Reprod Biol 1986;22:249-55.  Back to cited text no. 12
Beyers N, Moosa A, Bryce RL, Kent A. Depressed skull fracture in the newborn; a report of 3 cases. S Afr Med J 1978;54: 830-2.  Back to cited text no. 13
Van Enk A. Reduction of pond fracture. Br Med J 1972; 2:353.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]


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