Case: 2 Unicoronal synostosis

Case Report

6 months old child brought with abnormal head shape normal head circumference small Anterior frontanelle, hand foot normal, developmental milestones appropriate for age

Diagnosis investigation and plan of management?Hand and foot normal


What is it ?
What's the treatment ?
What if no Surgical treatment is done ?
Ideal age for surgery ?
Is our plan of treatment different if we see a child at 4 months ?
, or 8 months or 18 months ?

Description

Its Premature fusion of right coronal suture leading to Anterior plagiocephaly and compensatory left frontal bossing


What would the ideal age for surgery?
To understand the treatment plan of Craniosynostosis one has to know few things
50 % of brain growth happens antenatally, first year 25% of brain growth happen and second year another 15 % so when the child is 2 yrs 90 % of the brain growth is already done.
To accommodate rapidly growing brain nature has given 6 sutures, it's the intracranial compartment that is driving force for skull growth . Eg in hydrocephalus the macrocephaly and in hypoxic brain damage one have microcephaly .

so if once single suture fuses prematurely then the brain growth is not hampered since other sutures being open and brain growth remodels the skull and only the shape of the head is altered. if more than one sutures are Prematurely fused then there is abnormal shape of head and also raised intracranial pressure.


Indication for surgery in craniosynostosis is cosmetic and raised ICP  
If single suture its always cosmetic .and multiple sutures its cosmetic and raised ICP


Ideal age for surgery 
1] craniosynostosis surgery is associated with blood loss of at least 150 ml so larger the child better is the ability to handle the blood loss  we wait till child is at least 8 kgs 
2] periosteum and duramater is very osteogenic  in first 6 months  and after 12 months ability to form the bone decreases remarkably . if surgery is done before 6 months everything gets undone and if later then the bony islands will not be filled up . Given both the consideration best time would be 10-11 months age and child is 8 kgs weight in single sutural synostosis

However individual cases has to be managed as per its merits and tailored treatment is done

Its important to differentiate from posterior plagiocephaly with ipsilateral frontal bossing , if one look closely at the face the nose is deviated to the opposite side of the pathology and ipsilateral superior orbital rim is higher than the opposite site on XRay its know as harlequin eye deformity this leads to the vertical sqinting and compensatory torticollis


Lot of children present late taking treatment for torticollis when the pathology is unicoronal synostosis

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