See the corresponding editorial in this issue, pp 203204.

J Neurosurg Pediatrics 14:205211, 2014

AANS, 2014

Pediatric skull fractures: the need for surgical intervention,

characteristics, complications, and outcomes
Clinical article

Christopher M. Bonfield, M.D.,1 Sanjay Naran, M.D., 2 Oluwaseun A. Adetayo, M.D., 2

Ian F. Pollack, M.D.,1 and Joseph E. Losee, M.D. 2
Departments of 1Neurological Surgery and 2Plastic Surgery, University of Pittsburgh, Pennsylvania

Object. Head trauma is a common cause of morbidity and mortality in the pediatric population and often results
in a skull fracture. Pediatric skull fractures are distinct from adult fractures. Pediatric fractures have a greater capac-
ity to remodel, but the pediatric brain and craniofacial skeleton are still developing. Although pediatric head trauma
has been extensively studied, there is sparse literature regarding skull fractures. The authors aim was to investigate
the characteristics, injuries, complications, and outcomes of the patients in whom surgical intervention was needed
for skull fractures.
Methods. The authors performed a retrospective review of patients presenting to the emergency department of
a pediatric Level I trauma center between 2000 and 2005 with skull fractures. Patient demographics, mechanism of
injury, associated injuries, fracture bone involvement, surgical intervention, complications, and outcomes were ana-
lyzed. Groups treated nonoperatively, for skull fracture repair, and for traumatic brain injury were compared.
Results. A total of 897 patients with a skull fracture were analyzed. Most patients (n = 772, 86.1%) were treated
nonoperatively (Non-Op group). Fifty-eight patients (6.5%) underwent repair of the fracture (Repair group) and 67
(7.5%) required intervention for treatment of traumatic brain injury (TBI group). The Non-Op group was significantly
younger, and the TBI group had a lower initial Glasgow Coma Scale (GCS) score. A fall (51.2%) was the most com-
mon mechanism of injury in the Non-Op group, whereas a motor vehicle crash (23.9%) and being hit in the head with
an object (48.2%) were most prevalent in the TBI and Repair groups, respectively. Associated injuries were seen in
all 3 groups, with brain injury (hematoma) being the most common. Frontal bone fracture was seen most in the Repair
and TBI groups, and the parietal bone was the most frequent bone fractured in the Non-Op group. Patients in the TBI
group were much more likely to have 2 or 3 skull bones fractured. In the Repair group, 36.2% had a complication
(38.0% intervention related and 62.0% trauma related), but no patient had a worsening of their neurological status.
In the TBI group, 48.7% of the patients suffered a complication, the vast majority (90.6%) of which were related to
the trauma.
Conclusions. The majority of pediatric skull fractures can be managed conservatively. Of those requiring surgi-
cal intervention, fewer than half of the surgeries are performed solely for skull fracture repair only. Patients hit in the
head with an object or involved in a motor vehicle crash are more likely to need surgical intervention either to repair
the skull fracture or for TBI management, respectively. Frontal bone fractures are more likely to necessitate repair,
and those patients treated for TBI have a greater incidence of 2 or 3 bones involved in the fracture. Complications
occurred but most were related to underlying trauma, not the surgery. No patients who underwent intervention for
repair of their skull fracture only had a worsening of their neurological status.
(http://thejns.org/doi/abs/10.3171/2014.5.PEDS13414)

Key Words pediatric skull fracture head injury trauma

surgical intervention

H
ead trauma is common in the pediatric population
and is an important cause of morbidity and mortal-
ity in the United States, with an estimated incidence
Abbreviations used in this paper: EVD = external ventricular
drain; GCS = Glasgow Coma Scale; ICU = intensive care unit; LOS
= length of stay; MVC = motor vehicle crash; TBI = traumatic brain
injury.
of 250 per 100,000 per year. It accounts for over 7000
deaths, 60,000 hospitalizations, and 600,000 emergency
department visits annually among American children.8,12 In
children, between 10%30% of head injuries result in skull
fracture,7,9 many with associated brain injury.2,13 Surgical
intervention is largely performed in cases of skull fracture
depression, frontal sinus involvement, and underlying mass
lesion. In certain instances, especially in infants, conserva-

J Neurosurg: Pediatrics / Volume 14 / August 2014 205


tive management has been advocated as treatment.5,15 Pedi-
atric skull fractures remain distinct from their adult coun-
terparts. Pediatric skull fractures have a greater capacity to
heal and remodel, but the pediatric brain and craniofacial
skeleton are also still developing, which puts the children
at risk for unique complications, such as growing skull
fractures. Although pediatric head trauma has been ex-
tensively studied, there is sparse literature regarding skull
fractures, the rate of operative management, and outcomes
following surgical intervention in this population. Our goal
was to investigate the characteristics, injuries, indications
for intervention, and outcomes of the pediatric patients in
whom surgical intervention was needed for cranial vault
skull fractures.
Methods
The study was approved by the Institutional Review
Board at the University of Pittsburgh. A database of all
patients diagnosed with a skull fracture at the Childrens
Hospital of Pittsburgh from 2000 to 2005 was searched.
All patients diagnosed with a skull fracture were includ-
ed regardless of treating specialty, treatment modality,
or need for hospital admission. Patient demographics,
mechanism of injury, associated injuries, fracture bone
involvement, surgical intervention, complications, and
outcomes were recorded. Comparison was made between
individuals who were treated nonoperatively (Non-Op
group), those surgically treated for skull fracture repair
only (Repair group), and those surgically treated for trau-
matic brain injury (TBI) with or without repair of a skull
fracture (TBI group). Indications for intervention in the
Repair group included displaced or depressed fracture,
open fracture, frontal sinus fracture, and cosmetic defor-
mity. Patients in the TBI group had intervention for treat-
ment of the underlying trauma, and the group included
such operations as hematoma evacuation, decompres-
sive hemicraniectomy, external ventricular drain (EVD)
placement. Skull fractures may have been repaired in
the TBI group, but that was not the principal indication
for surgery. In general, for children younger than 2 years
of age, sutures were used to affix the bone. For children
older than 2 years of age, titanium plates and screws were
used. Data analysis was performed using SPSS version 17
(SPSS, Inc.). Chi-square tests were used for the between-
group comparisons of categorical variables. Since age,
length of hospital stay, and Glasgow Coma Scale (GCS)
score were not normally distributed, Kruskal-Wallis tests
were used for the comparisons of continuous variables.
Mean values presented SD.
Results
Patient Characteristics
A total of 897 patients presented to Childrens Hospi-
tal of Pittsburgh between 2000 and 2005 with a diagnosis
of a skull fracture. Of these patients, 772 (86.1%) were
treated nonoperatively (Non-Op group). The remaining
patients were grouped according to the indication for
their surgical intervention. Fifty-eight patients (6.5%) un-
206
C. M. Bonfield et al.
derwent repair of the fracture (Repair group) for fracture
elevation, frontal sinus repair, open fracture debridement,
or cosmetic repair. Sixty-seven patients (7.5%) required
intervention for treatment of a TBI (TBI group) including
hematoma evacuation, EVD placement, or decompressive
craniectomy.
Patient demographics are listed in Table 1. In all
3 groups, the majority of patients were male (63.5% in
the Non-Op, 69.0% in the Repair, and 65.7% in the TBI
group) and Caucasian (Non-Op 82.3%, Repair 81.0%,
and TBI 85.1%). The mean age at the time of evaluation
was significantly younger in the Non-Op group (5.5 5.0
years, p < 0.001) compared with the Repair (8.5 4.8
years) and TBI (8.6 5.2) groups.
Hospital Stay Data
Hospital stay data are also reported in Table 2. The
initial GCS score was significantly lower in the TBI
group (6.80 4.5, p < 0.001) in relation to the Non-Op
(13.6 3.4) and Repair (12.4 4.6) groups. In the TBI
group, 63 patients (94.0%) were admitted to the intensive
care unit (ICU) and 42 patients (62.7%) were intubated.
In the Repair group, 24 patients (41.4%) were admitted
to the ICU and 12 patients (20.7%) were intubated. The
Non-Op group had the lowest rates of ICU admissions
(19.4%) and intubations (10.0%). The length of stay (LOS)
also varied between the groups. The TBI group had the
longest LOS (16.0 13.0 days, p < 0.001), followed by the
Repair and Non-Op groups (5.3 7.0 days and 2.1 3.6
days, respectively).
Mechanism of Injury
The mechanisms of injury varied among the groups
(Table 3). The most common injuries sustained by the
Non-Op group were fall (n = 395, 51.2%), object to head
(n = 130, 16.8%), and motor vehicle crash (MVC; n = 85,
11.0%). In the Repair group, the most common mecha-
nisms of injury were object to head (n = 28, 48.2%), fall (n
= 8, 13.8%), and MVC (n = 6, 10.3%). The most common
injuries in the TBI group were MVC (n = 16, 23.9%), fall
(n = 12, 17.9%), object to head (n = 12, 17.9%), and pedes-
trian hit by motor vehicle (n = 8, 11.9%). The mechanisms
resulting in the highest percentage of surgical interven-
tion (Table 4) were bicycle accident (33.3% of total bi-
cycle accidents), object to head (23.5% of total objects to
head), and pedestrian hit by motor vehicle (22.0% of total
pedestrians hit by motor vehicle).
Fracture Location
Location of the fractures was also recorded (Table
5). Overall, the most common location was the parietal
bone (n = 269, 30.0%), followed by the frontal bone (n =
242, 27.0%). However, the most common bone fractured
differed among groups (p < 0.001). The parietal bone
was the most common fracture location in the Non-Op
group (n = 251, 32.5%), whereas the frontal bone was the
most injured in the Repair and TBI groups (n = 36, 62.1%,
and n = 18, 26.9%, respectively). In the repair group, 8
(22.2%) of 36 required surgery for frontal sinus repair
and 28 (77.8%) of 36 had treatment for elevation of a de-
J Neurosurg: Pediatrics / Volume 14 / August 2014
Surgery for pediatric skull fractures
TABLE 1: Summary of patient demographics

Treatment Group (%)

Variable Non-Op Repair TBI All
sex*
male 490 (63.4) 40 (69.0) 44 (65.7) 574 (64.0)
female 282 (36.5) 18 (31.0) 23 (34.3) 323 (36.0)
total 772 (100) 58 (100) 67 (100) 897 (100)
race
white 635 (82.3) 47 (81.0) 57 (85.1) 739 (82.4)
black 86 (11.1) 8 (13.8) 6 (9.0) 100 (11.1)
other/unknown 51 (6.7) 3 (5.2) 4 (6.0) 58 (6.5)
age (yrs)
mean 5.5 8.5 8.6 5.9
range 0.121.7 0.117.7 0.117.6 0.121.7
SD 5.0 4.8 5.2 5.1

* p = 0.67.
p = 0.92.
p < 0.001.

pressed fracture and cosmetic indications. The 18 patients
in the TBI group had underlying brain injuries that neces-
sitated intervention. The TBI group had the highest rate
of injuries involving 2 (23.9%) and 3 (7.5%) bones. The
Non-Op group (2 bones in 11.0% and 3 bones in 1.4%)
and the Repair group (2 bones in 13.8% and 3 in bones
0.0%) had lower rates of multiple bone involvement in
fractures. The fractured bones most likely to result in a
patient undergoing surgical treatment (Table 6) were 3
bones involved (31.3% of total 3 boneinvolved injury),
frontal bone (22.3% of total frontal bone injury) and 2
bones involved (22% of total 2 boneinvolved injury).
Associated Injuries
Many patients sustained injuries to other areas of
body besides the skull. Associated injury rates are re-
ported in Table 7. Intracranial hemorrhage (epidural,
subdural, subarachnoid, or intraparenchymal) was the
most common associated injury in all 3 groups (Non-Op
group: n = 326, 42.2%; Repair group: n = 23, 39.7%; and
TBI group: n = 57, 85.1%). The next most encountered
associated injury was orthopedic (n = 82, 10.6%) in the
Non-Op group, face (n = 9, 15.5%) in the Repair group,
and cardiac/pulmonary (n = 19, 28.3%) in the TBI group.
Procedures
The types of intervention in the surgical groups were
reviewed. All fractures, except one, in the Repair group
were depressed (n = 57, 98.3%), and 21 fractures (36.2%)
were open. These fractures underwent procedures for
elevation, repair, or debridement. The remaining patient
underwent the repair of a growing skull fracture 8 months
after the initial injury. In the TBI group, the most com-
mon procedure was the insertion of an EVD (77.6%).
The most common open surgical intervention was a de-
compressive craniectomy (22.4%), followed by epidural

TABLE 2: Hospital stay data

Treatment Group (%)

Variable Non-Op Repair TBI All
GCS score on admission*
mean 13.6 12.4 6.8 13.0
range 315 315 315 315
SD 3.4 4.6 4.5 4.0
ICU admission* 150 (19.4) 24 (41.4) 63 (94.0) 237 (26.4)
intubated* 77 (10.0) 12 (20.7) 42 (62.7) 131 (14.6)
LOS (days)*
mean 2.1 5.3 16.0 3.4
range 040.0 137 065 065
SD 3.6 7.0 13.0 6.4

* p < 0.001.

J Neurosurg: Pediatrics / Volume 14 / August 2014 207

 C. M. Bonfield et al.
TABLE 3: Mechanism of injury*

Treatment Group (%)

Injury Mechanism Non-Op Repair TBI All
ATV 23 (3.0) 2 (3.4) 4 (6.0) 29 (3.2)
bicycle accident 18 (2.3) 5 (8.6) 4 (6.0) 27 (3.0)
fall 395 (51.2) 8 (13.8) 12 (17.9) 415 (46.3)
gunshot wound 1 (0.1) 0 (0.0) 1 (1.5) 2 (0.2)
lawnmower accident 0 (0.0) 1 (1.7) 0 (0.0) 1 (0.1)
motorbike accident 9 (1.2) 1 (1.7) 1 (1.5) 11 (1.2)
MVC 85 (11.0) 6 (10.3) 16 (23.9) 107 (11.9)
NAT 33 (4.3) 0 (0.0) 6 (9.0) 39 (4.3)
object to head 130 (16.8) 28 (48.2) 12 (17.9) 170 (19.0)
pedestrian vs MVC 39 (5.1) 3 (5.2) 8 (11.9) 50 (5.6)
rollerblading/skateboarding accident 12 (1.6) 0 (0.0) 2 (3.0) 14 (1.6)
sledding accident 0 (0.0) 2 (3.4) 0 (0.0) 2 (0.2)
sports collision 27 (3.5) 2 (3.4) 1 (1.5) 30 (3.3)
total 772 (100) 58 (100) 67 (100) 897 (100)

* ATV = all-terrain vehicle; NAT = nonaccidental trauma.

p < 0.001 for all mechanisms between groups.

hematoma evacuation (17.9%). Other procedures in the infection or painful hardware necessitating removal.
TBI group were intraparenchymal hematoma evacuation Thirteen patients (62.0%) had complications related to the
(7.5%), penetrating injury exploration and repair (4.5%), trauma, such as new headaches or learning disabilities.
subdural hematoma evacuation (3.0%), and posterior fos- Of note, no patient in the Repair group had worsening of
sa hematoma evacuation (1.5%). any neurological condition (weakness, visual loss, hear-
ing loss, and so on) after repair of the fracture. Similarly,
Outcomes 32 patients (42.8%) in the TBI group had complications:
The length of follow-up was similar in the two surgi- 3 (9.4%) were surgery related, and included cranioplasty
cal groups (Repair 1.1 1.8 years, TBI 1.0 1.8 years). resorption and infection, and 29 (90.6%) were a result of
Complications in the surgical groups are recorded in Ta- the trauma, such as death, hydrocephalus, or weakness.
ble 8. In the Repair group, 21 patients (36.2%) had a re-
corded complication. Eight patients (38.0%) had compli- Discussion
cations related to the surgical procedure, such as wound
Head trauma is very common in the pediatric popula-
TABLE 4: Mechanism of injury and patients requiring operative tion and 10%30% of the injuries result in skull fractures.
intervention As in our series, there is a male predominance in most re-
ports on skull fracture.1,3,9,10,16 The most common cause of
Injury Mechanism No. of Cases* injury varies among reports, but mainly lists MVCs,1,10,15
ATV 6 (20.7)
falls,3,9,13 and assaults16 as the predominant mechanisms.
However, many of these studies do not differentiate be-
bicycle accident 9 (33.3) tween the age of the patients or those who received sur-
fall 20 (4.8) gical treatment for the fracture. In their large series on
gunshot wound 1 (50.0) surgical management of depressed skull fractures in
lawnmower accident 1 (100.0) children, Erahin et al. found falls and traffic accidents
motorbike accident 2 (18.2) to be the most common causes of injury.3 In our study,
MVC 22 (20.6) although a fall was the most common injury in patients
overall, those who most frequently had their fracture re-
NAT 6 (15.4)
paired were hit in the head by an object, and patients who
object to head 40 (23.5) required treatment for their trauma were mostly involved
pedestrian vs MVC 11 (22.0) in an MVC. High-impact injuries cause more force to the
rollerblading/skateboarding accident 2 (14.3) brain, so it is not surprising that these mechanisms, like
sledding accident 2 (100.0) MVC, lead to more traumatic injuries. Equally, getting
sports collision 3 (10.0) hit in the head directly with an object, such as a baseball,
a golf club, a tree branch, or a brick, has a high potential
* Parenthetical values are the percentage of the total of the respective to cause a depressed or open skull fracture. These are the
mechanism. fracture types that routinely undergo surgical repair.

208 J Neurosurg: Pediatrics / Volume 14 / August 2014

Surgery for pediatric skull fractures
TABLE 5: Fracture location
Fracture Location* Non-Op
frontal bone 188 (24.4)
temporal bone 129 (16.7)
parietal bone 251 (32.5)
occipital bone 108 (14.0)
2 bones 85 (11.0)
3 bones 11 (1.4)
* p < 0.001 for all fracture types between groups.
It is important to note that most patients in our large
series did not require surgical intervention for their skull
fracture. At birth, the skull is at 25% of its growth po-
tential, which expands rapidly to 75% by age 2 and to
95% by the age of 10.4,14 The rapid expansion and growth
allow for a greater healing and molding capacity in this
population. However, skull fractures, specifically those
involving the anterior cranial fossa base can also have
implications for orbital development. The growth of the
upper face is secondary to cerebral and ocular growth,
which is not completed until the age of 68 years, as well
as the frontal sinus, which begins the process of aeration
around age 45 years and progresses until puberty.4 It is
this lack of an aerated frontal sinus that makes it possible
to treat frontal bone fractures conservatively in the young
patient, unlike the teenage or adult patient. Intervention
should be performed with the goals of improved cosme-
sis, decreased infection, and improvement of neurological
defect that is the result of a depressed bone fragment or
underlying hematoma.
The location of the fracture on the skull is also im-
portant in determining the fracture treatment strategy.
In concordance with past reports, the parietal bone was
the most common bone fractured overall and in the Non-
Op group. However, individuals sustaining frontal bone
fractures were more likely to require surgical interven-
tion, whether for skull fracture repair or the treatment of
the underlying trauma. Frontal bone fractures are more
likely to involve the frontal sinus, skull base, and orbit
and to have an increased chance of causing a CSF leak,
ocular complications, and cosmetic deformity of the fore-
head. Therefore, especially in older children with aerated
TABLE 6: Fracture location and patients requiring operative
intervention
Fracture Location No. of Cases*
frontal bone 54 (22.3)
temporal bone 16 (11.0)
parietal bone 18 (6.7)
occipital bone 8 (6.9)
2 bones 24 (22.0)
3 bones 5 (31.3)
* Parenthetical values are the percentage of the total of the respective
mechanism.
J Neurosurg: Pediatrics / Volume 14 / August 2014
Treatment Group (%)
Repair TBI All
36 (62.1) 18 (26.9) 242 (27.0)
5 (8.6) 11 (16.4) 145 (16.2)
8 (13.8) 10 (14.9) 269 (30.0)
1 (1.7) 7 (10.4) 116 (12.9)
8 (13.8) 16 (23.9) 109 (12.2)
0 (0.0) 5 (7.5) 16 (1.8)
frontal sinuses, surgical repair is common. Parietal bone
lesions are generally covered by hair and have a good
chance of at least partially being remodeled without inter-
vention. Having 2 or more bones involved in fractures is
a factor associated with needing surgery, as well. Likely,
the increased rate of intervention is a result of a more
widespread fracture causing a larger cosmetic defect or a
greater area in need of repair. Also, having multiple bones
injured is a harbinger of a more serious and forceful trau-
matic event to the head, causing more damage to the skull
and underlying brain.
The majority of complications were a result of the
trauma, rather than the surgical procedure. The rate of
posttraumatic epilepsy has not been shown to decrease
after elevation of a fracture.1,6 Posttraumatic headaches,
learning disabilities, and behavioral problems are unlike-
ly to be caused or improved by surgical intervention. Ten
patients did die during their hospital admission as a result
of the severe brain trauma; however, no deaths occurred
after the initial hospitalization in any group.
Only 1 patient (0.1%), initially treated conservatively,
developed a growing skull fracture requiring a delayed
repair. In this case, the patient was an 8-year-old boy who
suffered a linear, nondisplaced fracture of his frontal
bone that extended into the orbit. He returned to the out-
patient clinic 8 months after the injury with a noticeable
defect in his frontal bone and swelling over the site. A CT
scan revealed a growing skull fracture and leptomeninge-
al cyst. He underwent open repair of his frontal fracture
and orbital rim. Approximately 22 months later, he pre-
sented with CSF rhinorrhea, which was repaired through
an endonasal endoscopic approach and a nasoseptal flap.
The patient required no further intervention. To prevent
these growing fractures, Sanford recommends surgically
exploring wide fractures in children in whom imaging
demonstrates brain herniation through the dura mater.11
Wound infection and complaints of painful hardware
did occur, and must be discussed when counseling the pa-
tient and family regarding the management options. The
complications requiring hardware removal all occurred
in patients in whom titanium plates were used. More re-
cently, absorbable plates and screws have been used more,
which could prevent these hardware complications. Im-
portantly, no patients who underwent surgery for repair of
the fracture only had a worsening of neurological status
after the intervention.
209
 C. M. Bonfield et al.
TABLE 7: Associated injuries

Treatment Group (%)

Associated Injury Non-Op Repair TBI All p Value
intracranial hematoma 326 (42.2) 23 (39.7) 57 (85.1) 406 (45.3) <0.0001
facial fracture 34 (4.4) 9 (15.5) 12 (17.9) 55 (6.1) <0.0001
spine 22 (2.9) 1 (1.7) 1 (1.5) 24 (2.7) 1.0
ophthalmological 31 (4.0) 6 (10.3) 12 (17.9) 49 (5.5) <0.0001
cardiac/pulmonary 24 (3.1) 1 (1.7) 19 (28.3) 44 (4.9) <0.0001
orthopedic 82 (10.6) 1 (1.7) 14 (20.9) 97 (10.8) <0.0001
abdominal/pelvic 22 (2.9) 1 (1.7) 17 (25.4) 40 (4.5) <0.0001

Conclusions Disclosure

Although the vast majority of children with skull
fractures do not require surgical intervention, it is im-
portant to understand the characteristics, indications, and
patterns of those patients who do. Of the fractures requir-
ing intervention, fewer than half are treated on the basis
of skull fracture elevation repair only. Being hit in the
head by an object is by the most common mechanism of a
fracture needing repair and an MVC is the most common
mechanism resulting in management of TBI. Patients sus-
taining a frontal bone fracture or having multiple skull
bones involved in the fracture are more likely to require
surgical intervention. The majority of complications are a
direct result of the traumatic event, not the surgical inter-
vention. No patients had worsening of a neurological defi-
cit after fracture repair, but complications such as painful
hardware and wound infections did necessitate further
interventions. An understanding of this population with
fractures will enable practitioners to better identify pa-
tients who may need surgical intervention and to counsel
patients regarding late sequelae of the trauma, fracture,
and intervention.
The authors report no conflict of interest concerning the mate-
rials of methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Bonfield, Losee.
Acquisition of data: Bonfield, Naran, Adetayo. Analysis and inter-
pretation of data: all authors. Drafting the article: Bonfield. Critically
revising the article: all authors. Reviewed submitted version of man-
uscript: all authors. Approved the final version of the manuscript on
behalf of all authors: Bonfield. Statistical analysis: Bonfield. Study
supervision: Pollack, Losee.
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TABLE 8: Complications in surgical groups

Patient Treatment Group

Repair* TBI
Surgery Related Trauma Related Surgery Related Trauma Related
concern over craniotomy defect deep venous thrombosis cranioplasty revision after resorption behavioral problems
CSF leak after growing skull fracture repair new headaches (5) hardware removal for pain 18 mos later death (10)
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wound revision & hardware removal 3 yrs motor weakness seizures (2)
later due to widening scar & pain
wound infection spasticity (2)
hydrocephalus (3)

* In the Repair group, 21 (36.2%) of 58 patients experienced a complication: 8 complications (38.0%) were surgery related and 13 complications (62.0%)
were injury related.
In the TBI group, 32 (47.8%) of 67 patients experienced a complication: 3 complications (9.4%) were surgery related and 29 complications (90.6%)
were trauma related.

210 J Neurosurg: Pediatrics / Volume 14 / August 2014

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Manuscript submitted August 11, 2013.
Accepted May 5, 2014.
Please include this information when citing this paper: pub-
lished online June 6, 2014; DOI: 10.3171/2014.5.PEDS13414.
Address correspondence to: Christopher M. Bonfield, M.D., 200
Lothrop St., Ste. B400, Pittsburgh, PA 15213. email: bonfieldcm@
upmc.edu.
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