Neurosurgery notes/Trauma/Primary head Injury/Fractures/Skull fractures

Skull fractures

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Fractures

Types of skull fractures

  • Closed (simple fracture)
    • Diastatic fractures extend into and separate sutures. More common in young children.
  • Open (compound fracture).

Linear skull fractures over the convexity

  • 90% of pediatric skull fractures are linear and involve the calvaria.
    • Differentiating linear skull fractures from normal plain film findings
        • Feature
        Linear skull fracture
        Vessel groove
        Suture line
        Density
        Dark black
        Gray
        Gray
        Course
        Straight
        Curving
        Follows course of known suture lines
        Branching
        Usually none
        Often branching
        Joins other suture lines
        Didth
        Very thin
        Thicker than fracture
        Jagged, wide
  • By themselves, linear skull fractures over the convexity rarely require surgical intervention.
  • Finding a linear skull fracture on radiologic exams in a conscious patient increases the risk of intracranial hematoma by how much?
    • 400-fold according to a study by Mendelow et al

Depressed skull fractures

  • For special considerations in paediatrics, see Depressed skull fractures in paediatrics section.
  • BTF:
    • Open depressed skull fracture
      • Indications for surgical treatment
        • Patients with open (compound) cranial fractures depressed greater than the thickness of the cranium should undergo operative intervention to prevent infection.
      • Indications for non surgical treatment
        • Patients with open (compound) depressed cranial fractures may be treated non-operatively if there is NO
          • Clinical or radiographic evidence of dural penetration,
          • Significant intracranial hematoma,
          • Depression greater than 1 cm,
          • Frontal sinus involvement,
          • Gross cosmetic deformity,
          • Wound infection
          • Pneumocephalus,
          • Gross wound contamination.
      • Timing
        • Early operation is recommended to reduce the incidence of infection.
      • Methods
        • Elevation and debridement is recommended as the surgical method of choice.
      • Primary bone fragment replacement is a surgical option in the absence of wound infection at the time of surgery.
      • All management strategies for open (compound) depressed fractures should include antibiotics.
    • Closed depressed skull fracture
      • Management of closed (simple) depressed cranial fractures is a treatment option.

Management

General

  • There is no evidence that elevating a depressed skull fracture will reduce the subsequent development of posttraumatic seizures, which are probably more related to the initial brain injury.

Antibiotics prophylaxis

  • Yes for all open skull fractures;
  • Current routine prophylaxis for all skull fractures is not supported by the available evidence

Closed (simple) depressed fractures:

  • May be managed surgically or nonsurgically

Open (compound) fractures

  • Indications for surgery
    • BTF
      • Open skull fractures depressed more than the thickness of the cranium or more than 5 mm below the adjacent inner table
      • Fractures with an underlying (expanding) hematoma.
    • ❌ more conservative treatment is recommended for fractures overlying a major dural venous sinus
      • Note: exception: depressed fractures overlying and depressing one of the dural sinuses may be dangerous to elevate, and if the patient is neurologically intact, and no indication for operation (e.g. CSF leak mandates surgery) may be best managed conservatively
    • Cosmesis

Timing of surgery

  • Early surgery to reduce risk of infection
  • Emergency surgery for expanding underlying haematoma

Surgical methods

  • Elevation and debridement are recommended
  • If there is no evidence of wound infection, primary bone replacement

Technical considerations of surgery

  • Surgical goals
    • Debridement of skin edges
    • Elevation of bone fragments
    • Repair of dural laceration
    • Debridement of devitalized brain
    • Reconstruction of the skull
    • Skin closure
  • Techniques
    • Open (compound) contaminated fracture/Fractures involving air sinuses
      • Excise depressed bone
      • To minimize the risk of infecting the flap, some surgeons follow the patient for 6–12 months to rule out infection before performing a cosmetic cranioplasty.
      • There has been no documented increase in infection with replacement of bone fragments; soaking the fragments in povidone-iodine has been recommended
    • Elevating the bone may be facilitated by drilling burr holes around the periphery and either using rongeurs or craniotome to excise the depressed portion
    • If a major dural sinus is lacerated and surgery is mandated, adequate preparation must be made for dural sinus repair;
      • NB: the SSS is often to the right of the sagittal suture
      • Prepare for massive blood loss
      • Have small Fogarty catheter ready to temporarily occlude sinus
      • Have dural shunt ready (Kapp-Gielchinsky shunt, ifavailable, has an inflatable balloon at both ends)
      • Prep out saphenous vein area for vein graft e) bone fragments that may have lacerated sinus should be removed last