Skull Fracture is a Head Injury in which there is an abnormal break in the skull bone that happens due to the application of any external force.
Although most of the cases of Skull Fractures are not significant in themselves, they can be associated with brain injuries, which make them potentially fatal.
When associated with brain injuries Skull Fractures are potentially fatal. They are usually seen in cases of head injuries such as during road accidents, physical assaults, violence, falls, or sport injuries.
Skull bones. The Fracture can involve the vault (i.e. the part of the skull bone that is seen from outside without opening the skull cavity) or the base (part of skull bones seen after opening the skull cavity). In most cases, brain is also involved due to an associated injury.
The skull bones are composed of three layers:
The outer table ( a layer of compact bone)
Diploe ( a layer of spongy bone, which is between the outer and the inner tables)
The inner table( a layer of compact bone)
When force is applied over a small area of skull, a cone like indentation occurs in the affected area. At the apex of such an indentation, the inner table is stretched and may be subsequently Fractured. But if the force is large enough, the outer table also Fractures. This type of Fracture occurs where the head is free to move at the time of trauma, such as in cases of road accidents, falls, physical violence, injury by a stick, rod, or a hammer.
But where head is compressed on both sides, the bones bulge in the area that is away from the compressed area. If the bulging is of sufficient degree it subsequently Fractures. In this case, the Fracture occurs away from the site of impact. This usually occurs in run over automobile accidents where head is compressed between the wheel and the ground or to a newborn during delivery, when instruments are applied to the head to facilitate delivery.
Most of the minor Skull Fractures are asymptomatic or can sometimes present with minor swelling over the affected area. This can be managed by applying simple firm pressure over the head. They are safe and heal by themselves, if not associated with brain injury.
Symptoms usually arise when there is an associated injury to the underlying brain. Some of the symptoms which points to the underlying brain injury are:
Drainage of clear fluid from the nose and ear: This fluid is the cerebro-spinal fluid (CSF), which is present in the brain and the spinal cord cavities .In case of Skull Fracture, CSF leaks from injured brain and drains from nose or ear. One can confirm if it is CSF, by collecting it on a cloth. Upon drying, the CSF produces a halo like clear ring on the cloth. This can also be sent to the laboratory to confirm the diagnosis.
Black Eyes: This happens when blood collects around the eyes. In cases of Skull Fracture associated with brain injury, the blood leaks from brain to collect around the eyes.
Bruising behind the ears.
Difficulty in maintaining balance while walking and standing.
Deafness: This can be temporary or permanent. Temporary deafness occurs if there is associated injury to ear bones. This can be repaired surgically. Permanent deafness occurs if there is injury to nerve cells responsible for hearing. This cannot be restored surgically as the damaged nerve cells cannot be repaired.
Seizures: Are mostly seen in children, and usually occurs in cases of depressed Fractures.
Paralysis or weakness of limbs: This can involve both upper and lower limbs on one side (Hemiplegia) or all the four limbs (Quadriplegia).
Apart from these, some minor symptoms such as drowsiness , irritability, visual disturbances, nausea, vomiting, or restlessness may also be observed.
If the symptoms suggest a head injury, neurological examination will be required to assess the various functions of the brain, such as:
Cognitive Functions: These pertain to the normal intelligence of an individual. This can be done by asking simple questions like the name, the time, or asking to recognize friends and relatives.
Motor Functions: This is done by checking if the injured person is able to move his/her limbs properly. The power of his/her muscles should also be assessed.
Sensory Functions: This is done by touching the person in several areas while his or her eyes are closed. The person is asked to tell if he or she can feel the touch or if there is any reduced sensation in any particular area.
Apart from this, various radiological tests should be conducted to detect the exact site and the extent of the injury. Some such tests are:
CT Scan: This is very useful in emergency management of head injuries. In this scan, various images of head are taken from different angles. Then they are arranged to form a cross dimensional image of head. This can give a clear view of any underlying brain injury. However, if one has any prosthetic implant (such as a heart valve, or an intra-medullary nail in a bone) is present in the body, the radiologist should be informed.
Skull X-ray: This is of limited value in Skull Fracture cases as it gives no idea about the underlying brain injury. However, a Fracture of vertex (the superior most part of the skull) can be seen more clearly on an x ray than on a CT scan.
MRI: This is of limited value in emergency management of Skull Fractures. It can be done to know the finer and residual details of injury.
Angiography: In this, a dye is injected into the blood vessels of the brain. Then the course of dye is studied on a visual monitor, as it travels along the blood vessel. This helps detect the exact site of any injury to the blood vessel as the dye will leak in such an area. In some cases, it is also possible to repair the vessel during angiography.
X-ray of spine: This is done to rule out any associated injury to spine.
X-ray chest and abdomen: This is done to rule out any associated injury to chest and abdomen.
As mentioned above, Skull Fracture is an asymptomatic condition in itself. Minor Fractures of skull heal by themselves. If there is any swelling or pain over the affected area, it should be pressed firmly. The effected person should be educated about the various signs and symptoms of brain injury (as mentioned above). He or she should be told to consult a doctor if any of such symptoms appear.
In case of any associated injury to the brain, following treatment may be considered:
Drugs for seizure control: Seizures are usually seen in children with depressed Fractures.
Antibiotics and tetanus toxoid: These are used in case of open Fractures i.e. when the brain is exposed through the Fracture. Open wounds or Fractures carry high risk of infection.
Drugs to control swelling of the brain: Injected mannitol is the most commonly used drug. Reducing swelling helps to reduce the intracranial pressure (the pressure inside the skull cavity).
Steroids: These are used in cases of associated Cranial Nerve Palsies, which are a common complication of brain injuries.
Some cases where surgical intervention is required are:
Depressed Fracture: In this the bone piece that is driven inward is pulled out surgically. This will help to relieve the pressure on the brain.
When there is gross contamination of the brain: Here the decontamination should be done surgically. This is required in cases of open Fractures.
If the clotted blood (a condition referred to as Hematoma) is compressing the brain underneath it. The Hematoma is removed surgically so as to relieve the pressure on the brain.
The most common surgeries done to open the skull cavity are:
Brain injury is the most common complication of Skull Fracture which makes it potentially fatal. This brain injury can be due to:
Injury to blood vessels of brain
Injury to nerve cells of brain
Apart from these, other potential complications are:
Cranial Nerve Palsies: They occur due to an injury to the cranial nerves. These are the nerves that originate from the brain. They are very prone to injury in cases of brain injuries.
Seizures: These are mostly associated with depressed Fractures in children and infants.
Growing Skull Fractures: In children, sometimes Linear Fissured Fractures widen with time instead of healing. This occurs due to the brain pulsations against the Fracture line. This can be repaired surgically using a bony graft.
As mentioned above Skull Fractures can be potentially dangerous. One should be aware of the first-aid measures to be taken in all such cases. Some such measures are:
Breathing and Circulation Should be Assessed: Breathing can be assessed by placing the fingers just below the nostrils. Smooth gushes of air to and from the nostrils suggest normal breathing. One should also look for any wheezing i.e. a whistle like sound in the breath. It suggests restricted breathing.
Circulation can be assessed by checking all the peripheral arteries such as:
Radial artery: On the front of the wrist in line of the thumb
Dorsalis pedis artery: On the middle of front of each foot
Femoral artery: On the middle of each thigh just below the waist
Carotid arteries: On the sides of neck.
Resuscitative Measures: If breathing or circulation is compromised, resuscitative measures should be started till medical help arrives. These measures are directed towards stabilizing the vitals of the person such as the cardiac and respiratory functions. They are mainly aimed at preventing fatality till a specific medical intervention is started. Some of the resuscitative measures are:
Stabilizing the head and the neck: Most cases of Skull Fractures are associated with an injury to the spine. Any further injury to the spine should be avoided. This can be done by placing both the hands firmly on the sides of head and below the shoulders. One should also avoid any turning of the head as that will twist the spine. The injured person should be kept in a comfortable position.
Preventing vomiting from entering the airways: This is done by turning the head to one side. But before this, the head and the neck should be stabilized as mentioned above. The trunk and the neck should be turned simultaneously along with the head so as to prevent the spinal cord from bending.
Controlling bleeding: This can be done by applying the firm pressure over the wounded area. If the bleeding is profuse, several layers of clothing should be used. Ice packs can also be used. Ice packs can be made by simply wrapping ice in a wash cloth. But direct application of ice on the wound should be avoided.
Apart from the above mentioned measures, one should call emergency medical services immediately. The lesser the time between the trauma and the medical intervention, the better the prognosis will be.
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