PATHOLOGIES AND PROCEDURES
The skull is hard, resilient and provides excellent protection to the brain (Heller, 2012; Khan, 2013). But a severe head injury caused by a blow or impact can fracture the skull and even injure the brain. Damage to the brain can be in the form of damage to the nervous system tissue and bleeding. It can also be in the form of blood clots under the skull that can press against brain tissue. A simple fracture breaks the bone without damaging the skin. A break on the cranial bone, which resembles a thin line, without splinters, depression or distortion is called a linear skull fracture. A break with a depression towards the brain is called a depressed skull fracture. And a break in the bone with splinters or loss of skin is called a compound fracture. Causes of all these fractures are head trauma, falls, automobile accidents, physical assault and sports injuries (Heller, Khan).
The thickness of the skulls is not uniform so that the impact of a blow or injury, which results in a fracture, depends on the location of the blow or injury (Khan, 2013). Fractures occur more at the base of the skull, at the thin squamous temporal and parietal bones, the sphenoid sinus, the foramen magnum, the petrous temporal ridge, and the inner parts of the sphenoid wings at the base of the skull. Other vulnerable points are the cribriform plate, the roof of orbits in the anterior cranial fossa, and between the mastoid and dural sinuses in the posterior cranial fossa (Khan).
Linear Skull Fracture
This is the most common type (Khan, 2013). It creates a break in the bone but without displacements and does not generally require medical intervention. It usually results from what is called low-energy transfer on account of blunt trauma on a large space of the skull. It affects the entire thickness of the skull. It is not considered serious unless it involves a vascular channel, a venous sinus groove, or a suture. Complications include epidural hematoma, venous sinus thrombosis, and suture diastasis. When the blow comes from a high-energy transfer, it results in a depressed skull fracture, which is serious (Khan).
In this type, the bone fragments are forced inward with or without damage to the scalp (Khan, 2013). It is usually comminuted with the fragments from the location of strongest impact and spreading out peripherally. In most cases, the frontoparietal region is involved where the bones are relatively thin. Moreover, this part is particularly exposed to an attack. This type is clinically significant. It requires elevation when fragments are depressed deeper than the adjacent inner table. It is either closed or open. Compound fractures may also be exposed if caused by skin lacerations or when it reaches the paranasal sinuses or the middle ear structures. This type of fracture may require corrective surgery (Khan).
Linear Skull Fracture
Skull fractures are primarily treated conservatively (Best Practice, 2011). Conservative treatment is generally given to linear or non-depressed skull fractures, including the basilar type. This is the option for as long as there is no evidence or suspicion of intracranial pathology, cranial nerve damage or CSF leak. This is also the choice if the neurological status is normal. Conservative treatment begins by eliminating present complications, such as CSF leak, seizure or infection (Best Practice).
Prophylactic Medications include anti-convulsants and antibiotics are not automatically given for isolated fractures (Best Practice, 2011). Anti-convulsants are prescribed by a neurosurgeon only in cases of underlying intracranial injury, such as subarachnoid hemorrhage or subdural/epidural hemorrhage or intra-parenchymal hemorrhage. This is given to prevent early traumatic brain injury associated with seizures and only for 7 days following the injury. The use of antibiotics has not been shown to benefit fractures with or without CSF leaks (Best Practice).
Depressed Skull Fracture
This is an open fracture or has intracranial effect or damage to cranial nerves or a CSF leak (Best Practice, 2011). It may require surgery. However, like non-depressed fractures, this is first treated conservatively. Operative elevation and repair do not always redound to any benefit in reducing the risk of seizure, infection or neurological damage. Operative elevation and repair of the dura and craniolplasty should be options for a patient who suffers from a depression bigger than 1 cm, has substantial cosmetic damage or deformity, some evidence of dural tear, or a fracture-associated and operable intracranial lesion (Best Practice).
Anti-convulsants should be given as prophylaxis for open depressed cases only or when fracture is associated with an underlying brain injury (Best Practice, 2011). Seizures can be therapeutically managed as a non-traumatic kind with benzodiazepines and anti-epileptic medications afterwards (Best Practice). #
Best Practice (2011). Skull fractures. BMJ Evidence Centre: BMJ Publishing Group,
Limited. Retrieved on September 25, 2013 from http://www.bestpractice.bmj.com/best_practice/monograph/398/treatment/step-by-step.html
Heller, J.L. (2012). Skull fractures. MedlinePlus: Adam, Inc. Retrieved on September 26,
2013 from http://www.nlm.nih.gov/medlineplus/ency/article/000060.htm
Khan, A.N. (2013). Imaging in skull fractures. Medscap: WebMD LLC. Retrieved on September 25, 2013 from http://www.emedicine.medscape.com/article/343764-overview