Skull fracture is a violation of the integrity of the bones of the skull. More often, it is caused by a severe direct injury. Pathology is accompanied by local pain at the site of injury. The remaining symptoms depend on the severity of the injury, damage to brain structures and the development of complications. Diagnosis is based on complaints, anamnesis and objective examination data, the results of radiography, CT, MRI and other studies. Treatment is determined by the type of fracture and the severity of traumatic brain injury, can be both conservative and operative.
ICD 10
S02.0 S02.1
Meaning
Skull fracture is a traumatic violation of the integrity of the skull. It is usually accompanied by damage to the brain and its membranes, therefore it belongs to a group of conditions that pose a danger to life. The tactics of treatment depends on the type of skull fracture and the features of damage to brain structures and can be both conservative and operative.
Skull fractures account for about 10% of all fractures and about 30% of the total number of severe traumatic brain injuries and are more often observed either in active young and middle-aged people, or in socially disadvantaged citizens (alcoholics, drug addicts, etc.). The high frequency of such injuries in the first group of patients is explained by their activity (injuries at work, driving cars, playing sports, including extreme sports, etc.). Injuries of representatives of the second group are more often associated with crime, or with accidents in a state of alcoholic or narcotic intoxication.
Causes
As a rule, a skull fracture occurs as a result of severe injuries: falls from a great height, car accidents, blows to the head with a solid massive object, etc. There are two mechanisms of skull fracture:
- Straight. In this case, the bone breaks directly at the point of application of force,
- Indirect. The impact effect is transmitted to the damaged bone from other parts of the skull or other bones of the skeleton.
Fractures of the cranial vault are usually formed as a result of direct trauma. In this case, the bones of the skull bend inward, and the inner plate of the cranial bone is damaged first. However, indirect fractures of the cranial vault are also possible, in which the damaged bone protrudes outward.
Fractures of the base of the skull are more likely to develop due to indirect trauma, for example, as a result of falling from a height to the legs and pelvis (in this case, the traumatic effect is transmitted through the spine) or as a result of falling on the head (in this case, the impact is transmitted from the bones of the vault to the bones of the base of the skull).
Classification
There are fractures of the cerebral and facial skull. The study and treatment of facial skull fractures is a separate branch of medicine administered by maxillofacial surgeons. Neurosurgeons are engaged in the treatment of fractures of the cerebral skull, and in villages and small towns that do not have their own neurosurgical departments – traumatologists or surgeons.
All fractures of the cerebral skull are divided into two large groups: fractures of the arch and the base. Fractures of the base in traumatology and orthopedics are relatively rare and account for about 4% of the total number of traumatic brain injuries. By their nature, arch fractures, in turn, are divided into:
- Linear fractures. The bone injury resembles a thin line. There is no displacement of bone fragments. Such fractures are the least dangerous in themselves, but they can cause damage to the sheath arteries and the formation of epidural hematomas.
- Depressed fractures. The bone is pressed into the skull. Because of this, the dura mater, vessels and medulla can be damaged, resulting in bruises and brain fractures, intracerebral and subdural hematomas.
- Comminuted fractures. When damaged, several fragments are formed, which can damage the brain and meninges, causing the same consequences as with depressed fractures.
Fractures of the base of the skull are divided into fractures of the anterior, middle and posterior cranial fossa. A combination of fractures of the arch and the base of the skull is also possible.
Skull fracture symptoms
Fracture of the cranial vault
If the cranial vault is damaged, a wound or hematoma of the scalp is detected. There may be visible or detectable indentations in the fracture area. It should be borne in mind that there are no such indentations in linear fractures. The general symptoms depend on the severity of the injury and the degree of damage to the brain structures. Any disturbances of consciousness are possible, from its short-term loss at the time of injury to coma. When the brain and cranial nerves are affected, sensitivity disorders, paresis and paralysis occur. Cerebral edema may develop, accompanied by nausea, vomiting, bursting headache, impaired consciousness and the appearance of focal symptoms. With compression of the brain stem, respiratory and circulatory disorders are noted, as well as inhibition of the pupil reaction.
Usually a pattern is revealed: the more severe the traumatic brain injury, the more pronounced the violation of consciousness. However, there is an exception to this rule – intracranial hematoma, which is characterized by a period of enlightenment, followed by loss of consciousness. Therefore, the satisfactory condition of the patient should not be regarded as evidence of the absence or minor severity of the injury.
Another factor that needs to be taken into account is that patients with a skull fracture are often intoxicated, which can make diagnosis difficult. Therefore, objective evidence of head trauma (bruises, wounds, hematomas) and eyewitness accounts in such cases should become a reason to refer the patient for immediate examination in a specialized department.
Fracture of the base of the skull
In fractures of the base of the skull, the symptoms depend on concomitant brain damage. In addition, signs characteristic of damage to a certain cranial fossa are revealed. The fracture of the anterior cranial fossa is indicated by the symptom of “glasses” – hemorrhages in the fiber around the eyes and the outflow of cerebrospinal fluid with an admixture of blood from the nose. Sometimes there is exophthalmos (bulging of the eyes due to hemorrhage into the fiber located behind the eye). If the air-bearing cavities are damaged, subcutaneous emphysema may be detected.
A fracture of the middle cranial fossa is accompanied by the outflow of cerebrospinal fluid from the auditory passages and the formation of a bruise on the back wall of the pharynx. A fracture of the posterior cranial fossa is characterized by severe respiratory and circulatory disorders (evidence of damage to the brain stem) and bruising in the mastoid process (a bony protrusion behind the ear). It should be noted that the symptom of “glasses” and bruises in the area of the mastoid process do not appear immediately, but 12-24 hours after the injury.
Diagnostics
Skull fracture should be excluded in all patients with traumatic brain injury. The doctor interviews the patient, finding out the circumstances of the injury, assesses his general condition, conducts a neurological examination (evaluates the sensitivity and strength of muscles, checks reflexes, etc.). During the examination, he checks the condition of the pupils (reaction to light, uniformity, width), the presence or absence of deviation of the tongue from the midline and the uniformity of the teeth, and also measures the pulse to identify bradycardia characteristic of traumatic brain injury.
An overview skull x-ray is necessarily performed in two projections, and, if necessary, in special stowings. Skull CT and magnetic resonance imaging (MRI of the brain) are prescribed.
There are a number of objective circumstances that make it difficult to diagnose skull fractures, including the serious condition of the patient, due to which it is impossible to conduct a number of studies, the features of the structure of the skull due to which damage to the bones of the base is detected in less than 10% of the victims, etc. Therefore, the diagnosis of a skull fracture in some cases is made on the basis of the clinical picture and subsequently, after the improvement of the patient’s condition, is confirmed by the data of objective studies.
Skull fracture treatment
First aid
All patients with traumatic brain injury should be taken to the hospital immediately. At the first aid stage, the patient is placed in a horizontal position. If the victim is conscious, he is placed on his back. Patients in an unconscious state are laid half-turned. To create such a position, small pillows or outerwear can be placed under the back on one side. The patient’s head is turned to the side so that when vomiting, he does not choke with vomit.
The head is created at rest using improvised means: clothes, pillows or rollers. Stop the bleeding by applying a pressure bandage to the wound. Cold is applied to the injury site. Check the patency of the respiratory tract, if necessary, eliminate tongue entanglement, free the airways from vomit, etc. According to the indications, analeptics (cytisine, nicotinic acid diethylamide) and cardiac glycosides are administered.
Conservative therapy
At the hospital stage, treatment of skull fractures is more often conservative, operations are carried out according to strict indications. Conservative therapy is prescribed to patients with fractures of the base of the skull, closed fractures of the cranial vault, subarachnoid hemorrhages, concussion and brain contusion. All patients are shown bed rest, the duration of which depends on the severity of the injury, and hypothermia of the head (ice bubbles are used). Dehydration therapy is carried out, antibiotics and painkillers are prescribed. In case of fractures of the base of the skull, repeated lumbar punctures are performed or lumbar drainage is applied.
The tactics of treatment in each case is determined by the severity and features of the traumatic brain injury. So, for concussions of the brain, patients are prescribed vasotropic and nootropic drugs. In case of brain bruises, the range of therapeutic measures expands and includes not only means to improve cerebral blood flow and energy supply to the brain, but also metabolic and anti-inflammatory therapy, etc. In the recovery period, nootropic drugs and medications are used to improve cerebral microcirculation (cinnarizine, vinpocetine).
Surgical treatment
Surgical treatment may be required for severe fractures of the skull, especially depressed ones. Under general anesthesia, trepanation is performed, during which the doctor creates a hole in the skull, removes embedded fragments, foreign bodies and destroyed tissues from the brain. The formation of intracranial hematomas in the vast majority of cases is an indication for an urgent operation, during which the surgeon removes the accumulated blood, washes the cavity, identifies and eliminates the source of bleeding.
Indications for surgical intervention in fractures of the base of the skull in the acute period may be damage to the facial or optic nerve, and in the long term – the continued outflow of cerebrospinal fluid from the ear passages or nasal passages. The prognosis for skull fractures depends on the severity of the traumatic brain injury. Full recovery is possible, as well as severe consequences that cause disability of the patient.