Unformatted text preview: Skull Deformities
in Pediatrics Case 1
Case 1 7wk female with parental concern over head shape PMHx: 35wk twin A; NICU x 6days (FEN, ID, bili)
Normal feeding/wets/stools Progressive “flattening” of head since birth
No hx IVH; no neurological symptoms
No flattening in twin Case 1
Case 1 Physical Exam: Ht, Wt, HC tracking Alert, NAD AFOSF, RR present Flattened R occiput, with protrusion of R forehead and R ear farther forward Mild flattening of L face O/W unremarkable What’s normal?
What’s normal? Skull growth mainly secondary to brain growth 40% adult size at term 90% adult size by 1yo 95% adult size by 6yo Suture closure PF 36mo AF 918mo C,S,L sutures 40years What’s most likely?
What’s most likely? Deformational Plagiocephaly:
Asymmetric head Up to 48% healthy infants Most common referral to Peds NSGY
Risk Factors: Intrauterine crowding/positioning Decreased mobility (dev.delay, MR, prematurity)
Posturing (torticollis, Cspine defect)
“Back to Sleep” campaign Increased physician awareness What’s the worry?
What’s the worry? Craniosynostosis: Premature closure of sutures
1 in 2,1003,000 live births Isolated (80%) vs. Syndromic (20%)
Risk Factors: Singlegene mutations (FGFR, TWIST, MSX2)
Rickets, hyperthyroidism Phenytoin, retinoids, VA, MTX, fluconazole What’s a Pediatrician to do?
What’s a Pediatrician to do?
The H&P, of course! Molding Pressure in AP dimension (labor)
Resolves in hoursweeks Deformation Pressure in local region (occipital)
No sutural ridging; bones mobile Synostosis Premature closure of sutures Palpable ridges over suture; bones immobile What’s normal?
What’s normal? PARALLELOGRAM TRAPEZOID Deformational Plagiocephaly Lambdoid Synostosis What’s not?
What’s not? Metopic Synostosis Bicoronal Synostosis What’s not?
What’s not? Sagittal Synostosis Deformational Plagiocephaly
Deformational Plagiocephaly AKA: Positional, Posterior, Occipital, Plagiocephaly without synostosis Diagnosis: Usually clear based on H&P
Head shape (parallelogram) Xray if unsure – sutures patent Deformational Plagiocephaly
Deformational Plagiocephaly Treatment: Repositioning Effective in 85% mild cases
Alternate sleeping sides Encourage “tummy time” Discourage carseats Helmet 23 hrs/day Frequent adjustments Typically does not require NSGY referral When to refer?
When to refer? True craniosynostosis
1/51/6 syndromic Increased risk ICP, hydrocephalus, Chiari MultiD Team: NSGY, Plastics, Ophtho, Neuro, ENT, Orthodontics, Psych, Genetics, Social Work Neurosurgery: 39 months old Case 2
Case 2 Newborn female, term SVD No maternal hx; no family hx Physical Exam:
Large, low AF ?Fused coronal/lambdoid sutures?
Hypertelorism Syndactyly on 3 extremities; clubfoot
Broad, flat hallux Case 2
Case 2 Craniofrontonasal Dysostosis
Xlinked Variable expression (F>M) Genetics eval Orthopaedics eval Ophthalmology eval Neurosurgery/OMFS eval ...
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- Fall '11
- Quadrilaterals, Deformational Plagiocephaly, Plagiocephaly Deformational Plagiocephaly, Deformational PlagiocephalyDeformational Plagiocephaly