Diastasis of the coronal suture with a difference

This 6-year-old boy presented with headache and vomiting 6 hours after a television tipover injury to the head. A CT scan and MR imaging with venography revealed diastatic disruption of the coronal suture extending 1.5 inches on either side of the midline with embedded skin under the fracture line (Fig. 1A). Because of the patient’s hair, this was not appreciated on initial scalp examination (Fig. 1B). There was a small epidural hematoma posterior to the embedded skin. We decided to operate as there was concern regarding skin viability and infection. An incision was made 1 cm posterior and parallel to the embedded skin edge. Using selfretaining retractors, we were able to remove the intact skin (1 × 3 inches) from underneath the fracture line (Fig. 1C). At 6-weeks’ follow-up, the skin was viable and intact (Fig. 1D). Television tipover is a significant cause of head injury in children.2 Concealed injuries, including embedding of foreign bodies in subcutaneous tissue or the skull, may be missed on initial examination of the scalp.1 In this case the television fell on the child’s head and its edge caused blunt injury leading to opening of the coronal sutures. The intact scalp was driven into the suture line and was entrapped. In closed skull fractures, galeal tissue or periosteum can be entrapped in the fracture line; but in the present case intact skin was embedded underneath the fracture line. To the best of our knowledge this has not been described before. (DOI: 10.3171/2010.8.PEDS1034)