Fractures of the clivus and traumatic diastasis of the central skull base in the pediatric population

Clinical article

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Object

Fractures of the clivus and traumatic diastases of the clival synchondroses are rare in the pediatric population. The incidence, outcome, and biomechanics associated with these fractures have been difficult to ascertain secondary to the lack of literature pertaining to their occurrence.

Methods

A Boolean search of the electronic medical record database at the Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, was performed to identify patients with fractures of the clivus that were diagnosed using CT of the head. A retrospective review of the chart and radiographic imaging was then performed to assess data regarding patient demographics, mechanism of injury, and skull and brain parenchymal injuries, as well as outcomes.

Results

Between May 2002 and November 2007, 16 patients with fractures of the clivus were identified. The mean age of these patients was 9 years (range 1–16 years). Eleven (68.8%) of the 16 patients had an associated traumatic diastasis of the central skull base. Five (31.3%) of the 16 patients died. However, of the 11 patients who survived, all had a good outcome with a Glasgow Outcome Scale score of 4 or 5 at the time of discharge. The incidence of clival fractures among patients with head injuries was 0.33%.

Conclusions

Clival fractures occur with a similar incidence in both the pediatric and adult trauma population. Outcome is not correlated directly with the extent of clival fracture, but rather with the presenting Glasgow Coma Scale score and concomitant brain parenchymal injuries. The identification of traumatic diastases in patients with clival fractures suggests that static loading forces are a significant factor in the biomechanics producing these types of fractures.

Abbreviations used in this paper: CN = cranial nerve; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; MVA = motor vehicle accident.

Article Information

Address correspondence to: Matthew A. Adamo, M.D., Division of Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, MC 10, Albany, New York 12208. email: matthew.a.adamo@gmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Axial CT scans demonstrating the 3 major clival fracture types. A: Case 9. Skull base image showing a longitudinal fracture located in the basisphenoid. B: Case 10. Typical transverse fracture pattern involving both carotid canals. Note that this fracture is separate from the sphenooccipital synchondrosis running just posterior and parallel to the fracture. C: Case 2. Representative image showing an oblique-type fracture also in the basisphenoid portion of the clival complex. Arrowheads denote fracture line. Insets: Classification of clival fractures is based on whether the fracture (irregular white line) crosses the petrous ridge or sphenooccipital reference lines (shaded boxed lines).

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    Axial CT scan showing clival synchondrosis and developmental anatomy of the basicranium in a normal 19-month-old child. At this age most of the clival synchondroses are not yet fused. 1 = sphenooccipital synchondrosis; 2 = petrooccipital (or petroclival) synchondrosis; 3 = anterior intraoccipital synchondrosis; 4 = occipitomastoidal suture.

  • View in gallery

    Axial CT scans of the skull base showing traumatic diastasis of the clival synchondroses. We identified 1 instance of sphenooccipital synchondrosis diastasis (A, Case 5), 7 instances of diastasis affecting the petrooccipital synchondrosis (B, Case 11), 10 instances of diastasis affecting the occipitomastoidal suture (C, Case 10), and 1 instance of diastasis affecting the anterior intraoccipital synchondrosis (D, Case 9). Arrows denote the area of the diastatic fracture.

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