Skull Injuries¶
Skull fractures are classified as being linear, depressed, or comminuted fractures that are further classified as closed or open (compound). A closed fracture is one in which there is no scalp or outside communication through the line of fracture.
Skull fracture as an injury per-se is seldom a critical injury; it is the potential associated injuries and complications that are the greatest concern. What is of primary concern with skull fractures is the possibility of concomitant injuries and complications such as dural tears and subsequent intracranial hematomas, cerebrospinal fluid leakage, brain contusion or laceration, fistula formation, cranial nerve damage, meningitis, pneumocephalus, and osteomyelitis.
Linear Skull Fracture¶
These are by far the most common of all skull fractures and the closed type is more prevalent than open linear fractures. They are usually a straight, single-line fracture with no bony fragments or displacement, although a stellate pattern (starlike) may be seen.
Most linear skull fractures occur in the parietal region of the skull and extend down to the base of the skull. Specific treatment is rarely required for linear, non-depressed, closed skull fractures. Linear skull fractures can have more serious consequences if they occur in the temporal or occipital regions. In these regions they could involve meningeal arteries or veins or dural sinuses causing intracranial hematomas.
Closed linear fractures heal spontaneously and usually only require a brief period of hospital observation and conservative treatment thereafter. Open linear fractures do pose the risk of infection, particularly osteomyelitis. The goal of treatment then is the treatment of the overlying laceration or contusion and the prevention of sepsis.
Depressed Skull Fractures¶
A depressed fracture describes a fracture where a portion of bone is pushed in towards the underlying brain. These fractures can be very severe and even fatal. Depressed skull fractures are also described as closed or open fractures.
Depressed skull fractures are associated with an increased risk of underlying dural sinus and brain injury and because of bone fragments also intracranial hemorrhage. In addition they have an increased risk of neurological deficit and epilepsy resulting.
Open depressed fractures have the additional risk of meningitis and brain abscess developing.
Depressed skull fractures may be treated conservatively or surgically, depending on whether there is risk of infection and the neurological status of the patient. Open depressed skull fractures are usually treated surgically.
Surgery involves decompressing the depressed bone. This is done by placing an instrument under the bone and elevating it. If elevation cannot be achieved this way, bur holes are drilled next to the fracture and any depressed fragments are removed through the bur holes. The site is then sterilized and the fragments replaced.
Infection is an ever-present complication from depressed fractures and these types of fracture also carry a higher risk of post-traumatic epilepsy than do linear fractures.
Most patients suffering depressed skull fractures make good recoveries although the injury has a higher risk of the development of posttraumatic epilepsy.
Comminuted Skull Fractures¶
This type describes a fracture where there are multiple fragments of bone. There is often severe deformity of the skull that requires subsequent cranioplasty. Treatment for comminuted fractures is the same as for depressed skull fractures.