Skull fracture in newborns

How does this happen?

A newborn skull is not one solid piece. It is several plates with gaps between them, which is what lets the head change shape during birth and lets the brain grow afterward. That flexibility protects against many injuries.

A fracture happens when force is concentrated on one point. The usual settings are a difficult delivery, pressure against the maternal pelvis, or an instrument-assisted birth. ²

Linear fractures are simple cracks. The bone stays in place and heals on its own.

Depressed fractures push a section of bone inward. In newborns the bone is soft enough that this often happens without a full break, producing a smooth dent that is compared to a dented ping-pong ball. Many of these lift on their own over weeks; some are elevated by a surgeon. ¹

The reason a fracture prompts a careful look at the brain is that the bleeding that matters, particularly an epidural hematoma, is usually found under a fracture. ¹

There is one late complication worth knowing about. If the membrane under the fracture is torn, the pulsation of the brain can gradually widen the gap over months. That is called a growing skull fracture, it is rare, and it is the reason follow-up imaging is sometimes arranged even when a baby is well.

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• A difficult delivery with pressure of the head against the pelvis.
• An instrument-assisted birth that was genuinely necessary, where the alternative was a worse outcome for the baby. ²
• breech delivery. ³
• A very fast delivery.
• A large baby in a tight pelvis. ⁴
• Bone fragility conditions, which are rare and which are considered when the pattern does not fit.

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Instruments used outside recommended limits, including prolonged application, repeated attempts, or continuing after there has been no progress. Guidance on operative vaginal birth addresses duration, attempts and when to abandon the procedure. ²
• Vacuum followed by forceps, or the reverse, which raises the risk to the baby. ²
• Incorrect placement of forceps. ²
• A fracture not identified before discharge, where a newborn examination is standard practice. ⁵
• Brain imaging not done in a baby with a skull fracture, so bleeding underneath went undetected. ¹
• Neurological signs not acted on, such as seizures, sleepiness or a bulging soft spot. ⁶

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• A visible or palpable dent in the head, in a depressed fracture.
• Bruising or swelling over the area.
• Often nothing at all, in a linear fracture.
• Signs that raise concern about what is underneath: seizures, sleepiness, poor feeding, vomiting, a bulging soft spot, or apnea.

The first week

• Swelling settling.
• Jaundice as any collected blood breaks down. ⁷
• Seizures, if there is underlying injury. ⁶
• A depressed area that may or may not be lifting.

Around 3 months

• Most fractures have healed by now.
• A depressed area that has not lifted may be reviewed for a procedure.
• A soft, pulsating swelling appearing at the fracture site is the warning sign for a growing skull fracture and needs assessment. ¹

Around 6 months

• Usually nothing.
• Head circumference tracking, if there was underlying injury. ⁸

Around 12 months

• No expected effects from an uncomplicated healed fracture.
• Where there was brain injury underneath, the picture follows that injury.

Toddler years

• No expected effects from the bone.
• Any effects follow the underlying brain injury rather than the fracture.

School age

• No expected effects from an uncomplicated fracture.

How is it diagnosed?

Examination. A dent, swelling, or bruising over the skull.

Imaging. CT scan is often used first because it shows both the bone and any fresh bleeding quickly. MRI shows brain detail better and avoids radiation, and is used where the baby is stable and brain injury is the question. ¹

cranial ultrasound is limited here. It is poor at the brain surface, which is exactly where bleeding under a fracture sits. A normal ultrasound does not rule it out. ¹

Observation for neurological signs: level of alertness, feeding, tone, seizures, and the fontanelle.

Bilirubin monitoring, since collected blood breaks down and can push levels up several days later. ⁷

Follow-up. Ask whether repeat imaging is planned. It is not always needed, and it is specifically used where there is concern about a growing skull fracture. ¹

What is the treatment?

Linear fractures usually need no treatment. They heal on their own. Observation and follow-up are the plan. ¹

Depressed fractures are managed case by case. Many lift on their own. Some are elevated by a neurosurgeon, particularly where the depression is deep, where there are neurological signs, or where there is bleeding underneath. Non-surgical techniques using suction are used in some centers for simple dents.

Bleeding underneath is managed on its own terms. An expanding epidural hematoma may need surgical drainage. ¹

Seizures are treated with medicine and guided by EEG. ⁶

Antibiotics if there is an open wound, which is uncommon.

Where there is underlying brain injury, referral to early intervention is free and does not require a confirmed diagnosis. ⁹

What is the long-term outlook?

For an isolated linear fracture with no bleeding and a normal examination, the outlook is excellent and no lasting effects are expected. ¹

For a depressed fracture without underlying injury, the outlook is also generally very good, whether the dent lifts on its own or is elevated.

Where there is bleeding or brain injury underneath, the outlook follows that injury rather than the bone. See intracranial hemorrhage.

The rare late complication is a growing skull fracture, which is why a new soft pulsating swelling at the site months later should be assessed. ¹

What does daily life look like?

For an uncomplicated fracture, ordinary newborn life with a follow-up appointment.

Families often feel considerable anxiety after being told their baby's skull is fractured, and the words sound far worse than the usual course. Ask directly: is there any bleeding, is the examination normal, and what are you watching for.

Where there is underlying injury, daily life follows that injury.

What does care cost over a lifetime?

An uncomplicated newborn skull fracture generates the cost of imaging and follow-up.

No agency publishes a cost estimate for this injury and this site does not invent one.

Where there is brain injury underneath, cost follows that injury. See the cost of care estimator.

What can you do this week?

1. Ask whether there is any bleeding under the fracture, and what imaging showed.
2. Ask whether it is linear or depressed, and what the plan is for each.
3. Ask what neurological signs they are watching for and what should make you call.
4. Ask whether bilirubin is being followed.
5. Ask whether repeat imaging is planned and why or why not.
6. If an instrument was used, ask which, how many attempts, and whether the cup detached. Request the operative note.
7. Ask about a soft pulsating swelling appearing later, so you know what to report.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the neonatologist or neurosurgeon

• Is this linear or depressed, and how deep?
• Is there any bleeding underneath?
• Does this need a procedure, or will it lift on its own?
• What neurological signs are you watching for?
• Is follow-up imaging planned?

For the obstetric team

• Was an instrument used, and which one?
• How many attempts, and were both vacuum and forceps used?
• What was the indication?
• Is it all in the operative note?

You can also build a printable list with the question generator.