skull bone and brain

• The brain is surrounded by cerebrospinal

fluid (CSF), enclosed in meningeal
covering, and protected inside the skull.
Furthermore, the fascia and muscles of
the scalp provide additional cushioning to
the brain.
 Linear fracture
• Linear fracture results from low-energy blunt
trauma over a wide surface area of the skull. It
runs through the entire thickness of the bone
and, by itself, is of little significance except
when it runs through a vascular channel,
venous sinus groove, or a suture. In these
situations, it may cause epidural hematoma,
venous sinus thrombosis and occlusion, and
sutural diastasis, respectively.
 Basilar skull fracture

basilar fracture is a linear fracture at the

base of the skull. It is usually associated
with a dural tear and is found at specific
points on the skull base.
Basilar skull fracture
 Temporal fracture

• Temporal bone fracture is encountered in

75% of all skull base fractures. The 3
subtypes of temporal fractures are
longitudinal, transverse, and mixed.
 Occipital condylar fracture
• Occipital condylar fracture results from a high-
energy blunt trauma with axial compression,
lateral bending, or rotational injury to the alar
ligament. These fractures are subdivided into 3
types based on the morphology and
mechanism of injury. An alternative
classification divides these fractures into
displaced and stable, ie, with and without
ligamentous injury.
Occipital condylar fracture
• Type I fracture is secondary to axial compression
resulting in comminution of the occipital condyle. This
is a stable injury.
• Type II fracture results from a direct blow, and,
despite being a more extensive basioccipital fracture,
type II fracture is classified as stable because of the
preserved alar ligament and tectorial membrane.
• Type III fracture is an avulsion injury as a result of
forced rotation and lateral bending. This is potentially
an unstable fracture.
 Depressed skull fracture
• Depressed skull fractures result from a high-energy
direct blow to a small surface area of the skull with a
blunt object such as a baseball bat. Comminution of
fragments starts from the point of maximum impact
and spreads centrifugally. Most of the depressed
fractures are over the frontoparietal region because
the bone is thin and the specific location is prone to
an assailant's attack. A free piece of bone should be
depressed greater than the adjacent inner table of
the skull to be of clinical significance and requiring
elevation
• A depressed fracture may be open or closed.
Open fractures, by definition, have either a skin
laceration over the fracture or the fracture runs
through the paranasal sinuses and the middle
ear structures, resulting in communication
between the external environment and the
cranial cavity. Open fractures may be clean or
contaminated/dirty.
 Imaging
• CT scan for skull fractures was found to have a
sensitivity of 85.4% and a specificity of 100% in
one study. In another study, of children with
skull fractures suspected of abusive head
trauma, CT with 3-dimensional reconstruction
was found to be 97% sensitive and 94% specific.
• MRI or magnetic resonance angiography is of
ancillary value for suspected ligamentous and
vascular injuries. Bony injuries are far better
visualized using CT scan.
 managment
• Adults with simple linear fractures who are
neurologically intact do not require any intervention
and may even be discharged home safely and
asked to return if symptomatic. Infants with simple
linear fractures should be admitted for overnight
observation regardless of neurological status.
• Neurologically intact patients with linear basilar
fractures also are treated conservatively, without
antibiotics. Temporal bone fractures are managed
conservatively, at least initially, because tympanic
membrane rupture usually heals on its own
• Simple depressed fractures in neurologically
intact infants are treated expectantly. These
depressed fractures heal well and smooth
out with time, without elevation. Seizure
medications are recommended if the chance
of developing seizures is higher than 20%.
Open fractures, if contaminated, may require
antibiotics in addition to tetanus toxoid.
Sulfisoxazole is a common recommendation.
• Types I and II
occipital condylar
fractures are
treated
conservatively with
neck stabilization,
which is achieved
with a hard
(Philadelphia) collar
or halo traction.
 surgery
is limited in the management of skull fractures. Infants
and children with open depressed fractures require
surgical intervention. Most surgeons prefer to elevate
depressed skull fractures if the depressed segment is
more than 5 mm below the inner table of adjacent
bone. Indications for immediate elevation are gross
contamination, dural tear with pneumocephalus, and
an underlying hematoma. At times, craniectomy is
performed if the underlying brain is damaged and
swollen. In these instances, cranioplasty is required at
a later date. Another indication for early surgical
intervention is an unstable occipital condylar fracture
(type III) that requires atlantoaxial arthrodesis. This can
be achieved with inside-outside fixation.
atlantoaxial arthrodesis
 Preoperative Details
• Blind probing of skull wounds should be
avoided. Patients are prepared for surgery,
and exploration is performed in the operating
suite under direct vision to prevent loose
pieces of bone from damaging the underlying
brain. Patients with open contaminated
wounds are treated with tetanus toxoid and
broad-spectrum antibiotics, especially in a
delayed presentation.
 intraoperative Details

• To maintain intracranial pressure, mannitol (1

g/kg) may be given at the beginning, and the
PaO2 should be kept at 30-35 mm Hg during
the surgery. Patients should be secured firmly
to the table, allowing Trendelenburg or reverse
Trendelenburg positioning if required. A lazy
"S" or a horseshoe-shaped incision is made
over the depression. A bicoronal incision is
preferred for forehead depressions.
• Bony fragments are elevated, and the dura is
inspected for any tears. If a dural tear is found, it
should be repaired. Special attention is given to
hemostasis to prevent postoperative epidural
collection. Bony fragments are soaked in
antibiotic/isotonic sodium chloride solution and are
reassembled. Larger pieces may be wired together.
Alternatively, titanium mesh also may be used to
cover the defect. Indeed, absorbable bone plates
and screws are recommended for use in children.
 Venous sinus tears
• Depressed fracture over a venous sinus poses a
unique situation requiring special attention. The
decision to operate is based on the neurological
status of the patient, the exact location of the sinus
involved, and the degree of venous flow compromise.
A preoperative angiogram with venous flow phase or
magnetic resonance angiography is recommended
whenever a depressed fracture is thought to be over
a venous sinus. Useful data regarding the position
and extent of occlusion and transverse sinus
dominance is obtained that can affect decisions
regarding surgery.
• A neurologically stable patient with a closed
depressed fracture over a venous sinus should be
observed. A patient with an open depressed
fracture over a patent venous sinus who is
neurologically stable should undergo skin
debridement without elevation of the fracture, but if
the patient is neurologically unstable, urgent
elevation of the depressed fragment is required. On
the other hand, if the patient is neurologically stable
and the sinus is thrombosed, it can be assumed
that ligation of the sinus can be tolerated.
 Postoperative
• Other than the usual immediate
postoperative care, the risk of intracranial
hematoma and venous sinus thrombosis
should be kept in mind in contaminated
depressed fractures.
 Complications
• Failure to recognize skull fracture has
more consequences than the
complications resulting from treatment.
The chance of a concomitant cervical
spine injury is 15%, and this should be
kept in mind when assessing a patient with
skull fracture.
 Linear skull fracture
In infants and children, a simple linear fracture, if
associated with a dural tear, can lead to
subepicranial hygroma or a growing skull fracture
(leptomeningeal cyst). This may take up to 6
months to develop, resulting from the brain
pulsating against a dural defect that is larger than
the bone defect. Repair of such a defect is
performed using a split-thickness bone graft.
leptomeningeal cyst
 Basilar skull fracture
• The risk of infection is not high, even without
routine antibiotics, especially with CSF
rhinorrhea. However, notably, facial palsy that
starts with a 2- to 3-day delay is secondary to
neurapraxia of the VII cranial nerve and is
responsive to steroids, with a good prognosis.
A complete and sudden onset of facial palsy at
the time of fracture usually is secondary to
nerve transection, with a poor prognosis.
 Depressed skull fracture
• In addition to the risk of infection in
contaminated depressed skull fractures, a risk
of developing seizures also exists. The overall
risk of seizures is low but is higher if the
patient loses consciousness for longer than 2
hours, if an associated dural tear is present,
and if the seizures start in the first week of
injury.
 Outcome and Prognosis
• skull fractures carry a significant potential risk
of cranial nerve and vascular injuries and direct
brain injury, most skull fractures are linear vault
fractures in children and are not associated
with epidural hematoma. Most skull fractures,
including depressed skull fractures, do not
require surgery. Hence, all of the potential
complications listed are associated with a
graver prognosis if the primary fracture is
missed during the diagnostic workup.
•END