Paramedian techniques not recommended: Older paramedian techniques may be difficult because of the thin (1–2 mm) bone in the lateral occiput of many children.
Midline occipital fixation:Modern midline occipital keel techniques help alleviate this problem. After exposing the occiput, an appropriately sized plate is selected. The wings can be bent to fit the occipital contour. The occipital holes are then drilled using drill guards, and a tap is used to prepare the bone for the screw. Two or three full-thickness screws are placed.