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PubMed1993

Immediate bone replacement in compound depressed skull fractures.

Twelve patients with compound depressed skull fractures whose post-debridement cranial defects were treated with immediate bone replacement (IBR) are described. All were fully conscious on admission and except one who had debridement two days after injury, all had surgery within 24 hours of wounding. None had post-operative wound infection or osteomyelitis of the replaced bone fragment. Four patients with severe or moderately severe head wounds had the comminuted free fragments removed without replacement. Primary repair of skull defects with bone fragments is recommended as the treatment of choice during debridement of compound depressed skull fractures of mild to moderate severity which present in hospital within 24 hours of injury.

Adolescent↗
PubMedDate not supplied

Scalp closure without fracture elevation does not reduce the risk of infection in patients with compound depressed skull fractures.

We conducted this study in order to determine whether suturing the scalp wound prior to referral for definitive surgery reduces the rate of wound infection in patients with compound depressed skull fracture and to propose guidelines for the initial management of the wound. We conducted a retrospective analysis of 79 patients with compound depressed skull fractures treated surgically in our unit between January, 1987 and August, 1998 and compared the rate of infection in patients who presented with open wounds with the rate in patients whose scalps were sutured prior to presentation to us. Adults and children were nearly equally represented in this study group. The male to female ratio was 3.6:1. Majority (49/79) of the fractures resulted from vehicular accidents. A total of 27 wounds were infected giving a rate of infection of 34%. Nine of the infections were present pre-operatively while the remaining 18 occurred post-operatively. Of the 52 patients with open wounds (OW) at presentation, 15 had wound infection. In the remaining 27 patients in whom the scalp had been sutured prior to referral (SW), there were 12 wound infections. There was no significant difference in the proportions of infected wounds between the two groups (X2 = 1.92, P > 0.5). In compound depressed skull fractures, suturing the scalp laceration alone prior to referral for definitive surgery did not reduce the rate of infection of the cranial wound. We recommend haemostasis, thorough irrigation of the scalp wound and application of sterile dressings prior to transfer for definitive management, in patients who do not have immediate access to neurosurgical care. Prospective studies are required to validate these findings.

Accidents, Traffic↗
PubMed1987

Management of simple depressed skull fractures in children.

Surgical elevation is the treatment usually recommended for a simple depressed skull fracture if the depression is more than the full thickness of the adjacent skull, but there is no clinical evidence to support this management. On that basis, a progressively more conservative approach to the treatment of this condition was adopted, especially in young children. Experience with this mode of management over the period 1972 to 1984 is presented. Of 111 patients under 16 years of age with depressed skull fractures, 64 had simple and 47 compound fractures. Simple depressed skull fractures occurred in a younger age group after less significant trauma than compound fractures. In those patients who were treated surgically, there was an 11% incidence of dural laceration in patients with simple depressed fractures versus 67% for the patients with compound depressed fractures. There was no difference in outcome between surgically and nonsurgically treated patients with simple depressed fractures with respect to the occurrence of seizures, neurological dysfunction, or cosmetic appearance. Surgical treatment prolonged hospitalization, and the only case with a fatal outcome was found in the group of patients treated surgically. It is suggested that the standard treatment of simple depressed skull fractures in the pediatric age group should not include surgery. Surgery is indicated when there is definite evidence of dural penetration and in the older child with an unacceptable cosmetic appearance.

Child↗
PubMed1993

Nonsurgical treatment of compound depressed skull fractures.

Classical treatment of compound depressed skull fractures includes debridement and closure of all scalp wounds to minimize the risk of delayed intracranial infection. In selected situations, a nonsurgical approach may prove to be equally safe. Over a 33-month period, we evaluated 1075 patients for head trauma. There were 63 patients with non-missile, compound depressed skull fractures (9 of these 63 patients have been excluded for deaths that occurred within 4 days of admission). Patients with significant intracranial hematomas or dural violations over the convexity of the brain underwent formal surgical therapy. Surgical therapy was performed on 28 patients (52%; age 33 +/- 3 years; ISS 24 +/- 2) and it consisted of craniotomy with debridement, elevation of depressed fragments, repair of dural tears, and evacuation of hematomas. Nonsurgical treatment was used if there was no evidence of violation of the dura mater and of significant intracranial hematoma. If the following criteria were satisfied, then the nonsurgical approach was employed: no evidence of exposed brain or a cerebrospinal fluid leak, no pneumocephalus related to the fracture, no depressed fragments of bone more than 1 cm below the inner table of the skull, and no gross wound contamination. Nonsurgical therapy was used on 26 patients (48%; age 34 +/- 3 years; ISS 19 +/- 2) and it consisted of wound irrigation, debridement, and closure. In all 54 patients of both subsets of patients, intravenous antibiotics were administered for 5 to 7 days. After two additional days of observation, off antibiotics, the patients were discharged. There were no infectious complications related to the central nervous system.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1997

Growing skull fractures: a clinical study of 41 patients.

Growing skull fractures are rare complications of head injury, occurring almost exclusively in infants and children under the age of three. A retrospective review at our Institute yielded 41 patients with this entity over a period of 20 years (1975-1995). The age at presentation ranged from less than 1 year to 62 years, with 33 (80.5%) patients being less than 5 years of age. The cause of injury was either a fall from a height (93%) or a road traffic accident. The most common location of a growing skull fracture was either parietal or frontoparietal (56%). One patient had a posterior fossa growing skull fracture. CT scan was performed in 19 patients which demonstrated an underlying porencephalic cyst, hydrocephalus or a cyst communicating with the ventricle. In 5 children, a ventriculo-peritoneal shunt alone was performed. Twenty four patients underwent a duro- and cranioplasty while a duroplasty alone was performed in 8 patients. The material used for cranioplasty included acrylic, wire mesh, steel plates or autologous bone. Three patients died, one due to an anaesthetic complication and two as a result of postoperative meningitis. Post-operative CSF leaks occurred in 3 patients, which were managed by a lumbar drain. Six patients had local wound infection.

Adolescent↗
PubMed1989

Clinical indicators of intracranial lesion on computed tomographic scan in children with parietal skull fracture.

We conducted a review of 98 cases of pediatric traumatic parietal skull fracture in which computed tomographic (CT) scans of the head were obtained during a seven-year period. There were 69 instances of an associated intracranial lesion identified in 47 children, including parenchymal injury (23), epidural hematoma (17), subdural hematoma (11), cerebral edema (ten), and subarachnoid hemorrhage (eight). Compared with 51 other children with parietal skull fracture and normal CT scans, the clinical characteristics significantly associated with the presence of an intracranial lesion were symptoms of neurologic dysfunction (loss or altered level of consciousness and/or seizure activity), neurologic compromise on examination (altered level of consciousness and/or focal deficit), or complicated skull fracture (bilateral, diastatic, and/or depressed). Of the 47 children with an intracranial lesion on CT scan, 44 had at least one of these significant clinical characteristics (sensitivity, 93%; specificity, 50%; positive-predictive value, 62%; and negative-predictive value, 96%). Children who sustain traumatic parietal skull fracture commonly experience associated intracranial injury. Those with evidence of neurologic deficit or complicated skull fracture are at particularly high risk, and should receive cranial CT scan evaluation.

Brain Injuries↗
PubMed2004

[Superior sagittal sinus occlusion caused by a compound depressed skull fracture: a case treated by emergency surgery].

Depressed skull fractures compressing major venous sinuses are rare, and the treatment is a matter of controversy. The majority of depressed fractures are treated conservatively for fear of bleeding from venous sinuses, but surgical intervention was conducted in a few cases. We report a case of a 59-year-old man with a compound depressed fracture occluding the superior sagittal sinus (SSS). The patient was struck on the head by a heavy iron bar and admitted to our emergency center because of deterioration of consciousness. A computed tomographic scan showed depressed skull fracture overlying the SSS with hemorrhagic lesions in the bilateral parietal lobes and an acute epidural hematoma at the right temporoparietal convexity. Digital subtraction angiography (DSA) showed an occlusion of the SSS and compensatory venous drainage associated with poor capillary filling in the left parietal lobe. On an emergency basis, bone fragments compressing the SSS were surgically removed piece-by-piece to resolve severe venous congestion and to avoid infection. A small tear in the SSS was treated by head elevation and compressing the SSS with Gelfoam. Postoperative DSA confirmed the patency of the SSS and normal blood flow in the left parietal lobe. The patient exhibited slight disorientation and was transferred to another hospital for further rehabilitation. Because of symptomatic severe venous congestion, we had to perform emergency surgical decompression and removal of bone fragments. Treatment strategy for depressed skull fracture with SSS involvement was discussed with review of the literature.

Decompression, Surgical↗
PubMed1993

[A growing skull fracture: a case report].

A case of growing skull fracture was reported with some considerations on the literature. At the age of 1 year, the patient fell down stairs and struck the right occipital region, but did not receive any treatment at that time. At the age of 19 years, he suffered from several epileptic attacks and was admitted to our ward. Plain craniograms showed a right occipital bone defect measuring 7 x 3 cm in size. CT scan demonstrated a cystic lesion just beneath a membranous substance existing at the bone defect. MRI revealed cystic encephalomalacia underlying the cyst very clearly. At the operation the bone defect was found to be replaced by the granulation tissue which was examined microscopically. Under the granulation tissue, a cyst filled with yellowish fluid and surrounding gliotic brain was found. The dural tear was noticed to be much wider than the bone defect. A dural plasty with LYODURA and a cranioplasty with methacrylic resin were performed. Microscopic examination revealed the granulation tissue to be a fibroglial cicatrix. According to these findings, we concluded that the contused and swollen brain tissue which had herniated through the dural tear had enlarged the skull fracture and formed a fibroglial cicatrix with subcutaneous tissue. It is emphasized that MRI combined with CT scan is an indispensable procedure for diagnosis of growing skull fracture, and microscopic examination contributes to an understanding of its pathogenesis.

Adult↗
PubMed1998

Basal skull fracture with traumatic polycranial neuropathy and occluded left carotid artery: significance of fractures along the course of the carotid artery.

A patient who survived with traumatic multiple cranial nerve palsies and occluded internal carotid artery associated with a basal skull fracture that involved the carotid canal is described. A literature review indicates that a wide variety of injuries can occur to the carotid artery as it passes through a fractured skull base. Basal fractures involving the course of the carotid artery reflect a significant risk of carotid injury.

Accidents, Traffic↗
PubMed1986

Periorbital skull fractures in five horses.

Periorbital skull fractures were diagnosed in 5 horses, and were associated with ophthalmic complications including corneal ulceration, uveitis, and entrapment of the eye by retrobulbar bone fragments. Physical examination was of greater diagnostic use than radiography. Surgical repair was performed on all horses and was associated with a more favorable postoperative appearance in horses treated acutely; however, the cosmetic results were considered acceptable in all horses. Major postoperative complications were not observed.

Animals↗
PubMed1982

[Classification and grading of facial skull fractures (author's transl)].

It is well known that certain kinds of fractures of the facial skull occur repeatedly. In attempting to classify our own patients we came to the conclusion that an easy categorizing into the known schemes is rarely possible. Therefore, we propose a new classification based on 353 facial skull fractures, treated in our clinic during the last eight years. In doing so, we take into account not only the localization of the fracture, but also the degree of the injury in the form of a grading. Both of the large groups, lateral and central facial skull fractures, are further divided into isolated fractures of particular localisations (zygomatic arc, orbital floor fracture etc.) and compound fractures of varying degrees (lateral or central impression fractures of the mid-face Grade I-III). This classification, based on practical experience, allows the majority of all existing injuries to be freely categorized.

Facial Bones↗
PubMed1997

Skull fractures in infants and predictors of associated intracranial injury.

BACKGROUND: Emergency department (ED) management of skull fractures in children remains controversial. Because infants incurring head trauma have a high incidence of skull fracture, we chose to describe fractures in this subset of patients and to determine if there are clinical predictors of associated intracranial injury (ICI) that may have utility in developing more efficient management schemes in these patients. METHODS: A retrospective medical record review was conducted on all awake patients < 13 months of age with an acute skull fracture from non-birth trauma, presenting to the ED of a university-affiliated children's hospital during a three-year period. Clinical and radiographic data extracted were used to describe skull fractures in these patients. The ability of various characteristics to determine the presence of ICI was assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value for each. RESULTS: The predominant mechanism of injury for the 102 infants was falls (91%). Suspicion of abuse was found in only one case. The parietal bone was fractured in 87 infants, and 34 had nonparietal fractures. The most prevalent fracture type was linear (92 infants), and 31 had > 1 cranial bone fractured. CT scans obtained on 32 infants (CT group) revealed 21 ICIs in 15 patients. Two with temporoparietal fractures required emergent evacuation of epidural blood. In the CT group, seven of the 15 (47%) with ICI (ICI group) were lethargic compared to two of the 17 (12%) without ICI (No ICI group) (P = 0.035). Five (33%) in the ICI group had temporal bone fractures compared to 0 in the No ICI group (P = 0.015). The presence of any sign or symptom had a sensitivity and negative predictive value of 100%, but only a specificity of 35%. The presence of lethargy had a positive predictive value of 78%. The presence of temporal and frontal bone fractures had positive predictive values of 100 and 75%, respectively. CONCLUSION: This study reports a high prevalence of fracture characteristics often associated with inflicted injury in other studies when virtually all injuries in our sample were accidental. Several clinical characteristics were demonstrated to be potentially useful in predicting ICI associated with skull fracture; however, prospective study is recommended to validate these findings prior to clinical application.

Accidental Falls↗
PubMed1995

"High risk" anterior basal skull fractures. Surgical treatment of 64 consecutive cases.

Anterior Basal Skull Fractures (ABSFs) may be complicated by Cerebrospinal Fluid (CSF) fistulae and intracranial infections. An initially non-operative management is usually suggested since most fistulae spontaneously stop within a few days thus requiring no surgical repair. However, if the fistula fails to stop or recurs, surgical treatment is to be considered. Furthermore, if the fracture is complicated by meningitis, there is a relative risk of recurring infections and surgical repair may be also considered. Finally, surgical repair may be suggested in cases of compound, comminuted, depressed, largely extended cranio-facial fractures (the so-called "fracas craniofaciaux") where spontaneous healing is considered unlikely and risk of infection is high. Accordingly we termed "high risk" fractures those associated with active (persistent or recurring) cerebrospinal fluid fistula, those with meningitis and the so-called "fracas craniofaciaux". In this paper, we report our personal experience in surgical treatment of 64 consecutive "high risk" anterior basal skull fractures. Thirty-seven patients had persistent or recurring fistulae, ten had intracranial infections and seventeen had severe bone derangement of the anterior skull base. The osteodural repairs were performed through bilateral or unilateral subfrontal approach. In 59 cases the initial procedure was successful whereas 4 patient needed additional surgery but were ultimately successfully treated. One patient died. No major permanent neurologic or neuropsychologic impairments were reported. On the basis of our experience, we think that intracranial repair is a very suitable treatment modality in facing "high risk" anterior basal skull fractures.

Aged↗
PubMed1998

An unusual variant of a growing skull fracture in an adolescent.

A great majority of growing skull fractures occur in infancy and earlychildhood. Since the growth of brain is necessary as a driving force for these lesions to occur, almost all reported cases have been before the first 3 years of life. Although a number of uncommon locations, such as basiooccipital and skull base areas, have been reported, they are commonly located on calvaria. The authors report a growing skull fracture on the orbital roof in a 16-year-old female admitted to hospital with complaints of headache and seizures. She had had an orbital trauma 8 years before. CT scan revealed a hypodense lesion in the right frontal lobe and a diastatic fracture line on the right orbital roof. A right craniotomy was performed. Excision of arachnoid loculations and duraplasty were carried out. This is an unusual condition with respect to the location of the lesion, as well as the age of the patient.

Adolescent↗
PubMed1997

Conservative management of extradural haematomas: effects of skull fractures on resorption rate.

In conservative management of extradural haematomas (EDH), several mechanisms were described to explain the resorption of the haematoma. One of these was the transfer of the clot into the epicranial space through the skull fracture. In this study, the effects of skull fracture and associated intracranial lesions in the conservative management of EDH were investigated. Skull fracture and associated intracranial lesions were found in 71.11% and 51.1% of the patients, respectively. Resorption rate was calculated using an original formula and it was 0.548 +/- 0.227 in patients with skull fracture and 0.507 +/- 0.170 in patients with both skull fractures and additional intracranial lesions. These rates were found to be significantly higher than in the patients without fracture. In conclusion, in the patients with EDH planned to be managed conservatively, skull fracture and additional intracranial lesions must not be thought as risk factors, on the contrary, resorption of the clot might be earlier than in the others.

Absorption↗
PubMed1980

Skull fractures in infant squirrel monkeys (Saimiri sciureus).

Skull fractures resulting from trauma and leading to hemorrhage in the subdural area and brain parenchymal have been a common cause of neonatal mortality in a breeding colony of squirrel monkeys. The skull fractures may have been caused by abnormal carrying behavior by the dam or by the dam being frightened while cradling the infant during nursing.

Animals↗
PubMed1998

Management of uncomplicated skull fractures in children: is hospital admission necessary?

OBJECTIVE: This study was undertaken to determine the necessity for routine hospital admission of children with skull fractures, a normal neurological exam, a normal head CT, and no other injuries ('uncomplicated skull fracture'). METHODS: A prospective study of closed-head injuries in children was done over a 2-year period at St. Louis Children's Hospital. All patients with closed head injuries underwent skull radiographs and a head CT scan. From this cohort, children with uncomplicated skull fractures were identified and studied. For comparison, a retrospective analysis was also performed of the hospital admission records of children admitted over a 5-year period (1990-1994) with the diagnosis of epidural hematoma (EDH) to identify the typical time intervals between injury and documentation of the lesion in these cases. RESULTS: Forty-four patients with uncomplicated skull fractures were identified; all had been admitted for observation. Mean age was 1.8 years. Average time between injury and hospital admission was 6.35 h with half of this time being spent in the emergency room. Average LOS was 35 h, but 50% of patients were hospitalized less than 24 h. No patient in this study group suffered a complication related to their inury. Twenty-three patients with EDH had been admitted during the 5-year review period. Slightly more than one-half of patients had their EDH detected within 6 h of injury. The others were diagnosed more than 6 h after injury due to a delay in medical evaluation or a delay in obtaining a computed tomographic (CT) scan after an initial medical evaluation. CONCLUSIONS: Patients with uncomplicated skull fractures, in the absence of recurrent emesis and/or evidence of child abuse, can be considered for discharge home. The definition of an uncomplicated skull fracture requires that a head CT be performed on these patients.

Adolescent↗