Skull fractures may be simple (closed) or compound (open) and mayor may not displace bone fragments. Skull fractures are further described as linear, comminuted, or depressed. A linear fracture is a common hairline break, without displacement of structures; a comminuted fracture splinters or crushes the bone into several fragments; a depressed fracture pushes the bone toward the brain.
CLINICAL TIP Because possible damage to the brain is the first concern, rather than the fracture itself, a skull fracture is considered a neurosurgical condition.
In children, the skull's thinness and elasticity allow a depression without a fracture (a linear fracture across a suture line increases the possibility of epidural hematoma).
Skull fractures are also classified according to location, such as a cranial vault fracture; a basilar fracture is at the base of the skull and involves the cribriform plate and the frontal sinuses. Because of the danger of grave cranial complications and meningitis, basilar fractures are usually far more serious than vault fractures.
Like concussions and cerebral contusions or lacerations, skull fractures invariably result from a traumatic blow to the head. Motor vehicle accidents, bad falls, and severe beatings (especially in children) top the list of causes.
Signs and symptoms
Suspect brain injury in all patients with a skull fracture until clinical evaluation proves otherwise. Every suspected skull injury calls for a thorough history of the trauma and a CT scan to attempt to locate the fracture. (Keep in mind that vault fractures often aren't visible or palpable. )
A fracture also requires a neurologic examination to check cerebral function (mental status and orientation to time, place, and person), LOC, pupillary response, motor function, and deep tendon reflexes.
Using reagent strips, the draining nasal or ear fluid should be tested for CSF. The tape will turn blue if CSF is present; it won't change in the presence of blood alone. However, the tape will also turn blue if the patient is hyperglycemic.
The patient's bedsheets may show the halo sign - a blood-tinged spot surrounded by a lighter ring - from leakage of CSF.
Brain damage can be assessed through a CT scan and magnetic resonance imaging, which disclose intracranial hemorrhage from ruptured blood vessels and swelling. Expanding lesions contraindicate lumbar puncture.
Effective treatment depends on the type and severity of the fracture.
Although occasionally even a simple linear skull fracture can tear an underlying blood vessel or cause a CSF leak, linear fractures generally require only supportive treatment, including mild analgesics (such as acetaminophen), and cleaning and debridement of any wounds after injection of a local anesthetic.
If the patient with a skull fracture has not lost consciousness, he should be observed in the emergency room for at least 4 hours. After this observation period, if vital signs are stable and if the neurosurgeon concurs, the patient can be discharged. At this time, the patient should be given an instruction sheet to follow for 24 to 48 hours of observation at home.
Vault and basilar fractures
More severe vault fractures, especially depressed fractures, usually require a craniotomy to elevate or remove fragments that have been driven into the brain and to extract foreign bodies and necrotic tissue, thereby reducing the risk of infection and further brain damage. Other treatments for severe vault fractures include antibiotic therapy and, in profound hemorrhage, blood transfusions.
Basilar fractures call for immediate prophylactic antibiotics to prevent the onset of meningitis from CSF leaks as well as close observation for secondary hematomas and hemorrhages. Surgery may be necessary.
In addition, basilar and vault fractures often require dexamethasone I. V. or I.M. to reduce cerebral edema and minimize brain tissue damage.
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