Steve Schultz

Advanced Emergency Care

Dr.Mann
4/19/07

Skull Fractures

Head injuries are one of the most common causes of disability and death in adults. The

injury can be as mild as a bump, bruise (contusion), or cut on the head, or can be moderate to

severe in nature due to a concussion, deep cut or open wound, fractured skull bone(s), or from

internal bleeding and damage to the brain (Head Injury). A head injury is a broad term that

describes a vast array of injuries that occur to the scalp, skull, brain, and underlying tissue and

blood vessels in the head. Head injuries are also commonly referred to as brain injury, or

traumatic brain injury (TBI), depending on the extent of the head trauma (Head injury in adults).

A skull fracture is a crack or break in one of the skull's bones. In some cases, the skull is

dented inward so that fragments of shattered bone are pressed against the surface of the brain.

This is called a depressed skull fracture. Other types of skull fractures include: simple skull

fracture which is a break in the bone without damage to the skin, linear or hairline skull fracture

which is a break in a cranial bone resembling a thin line, without splintering, depression, or

distortion of bone, and compound skull fracture which is a break in or loss of skin and splintering

of the bone. Along with the fracture, brain injury, such as subdural hematoma (bleeding) may

occur (Skull Fracture). Although the skull is tough, resilient, and provides excellent protection

for the brain, a severe impact or blow can result in fracture of the skull. It may be accompanied

by injury to the brain. In most cases, a skull fracture causes a bruise (contusion) on the surface

of the brain under the fracture. Skull fracture increases the chances of an intracranial hematoma

by 400 times (Head Injury).

 Skull fractures can injure arteries and veins, which then bleed into the spaces around

brain tissue. In people with a skull fracture, brain damage may be more severe than in people

with a head injury but no fracture. Fractures, especially at the back and bottom (base) of the

skull, can tear the meninges, the layers of tissue that cover the brain. Bacteria occasionally enter

the skull through such fractures, causing infection and severe brain damage. However, a skull

fracture often occurs without brain damage. Skull fractures can be detected by x-rays, computed

tomography (CT), or magnetic resonance imaging (MRI) (Qureshi, Skull Fracture).

Depressed fractures have the highest risk of tearing the dura, damaging the underlying

brain, or both. If temporal bone fractures cross the area of the middle meningeal artery, an

epidural hematoma is likely. Fractures crossing one of the major dural sinuses may cause

significant hemorrhage and venous epidural or venous subdural hematoma. Fractures that

involve the carotid canal can result in carotid artery dissection. Because the occipital bone and

base of the skull (basilar bones) are thick and strong, fractures in these areas indicate a high-

intensity impact. Basilar skull fractures that extend into the petrous part of the temporal bone

often damage middle and inner ear structures and can impair facial, acoustic and vestibular nerve

function. In younger athletes, the meninges may become trapped in a linear skull fracture with

subsequent development of a leptomeningeal cyst and growth of the original fracture, or growing

fracture (Skull Fracture).

A skull fracture is a medical emergency that must be treated promptly to prevent

possible brain damage. Such an injury may be obvious if blood or bone fragments are visible. It

is possible for a fracture to have occurred without any apparent damage. A skull fracture should

be suspected if any of the following are observed: headache, loss of consciousness, confusion,
convulsions, restlessness, irritability, drowsiness, slurred speech, difficulties with balance, visual

disturbances, nausea and vomiting, swelling, changes in pupils (anisocoria,) sensitivity to light

(photophobia) (Qureshi). Certain symptoms suggest a fracture at the base of the skull:

Cerebrospinal fluid, the clear fluid that flows over the surface of the brain between the meninges,

may leak from the nose or ears. If the eardrum is ruptured, blood may collect behind the eardrum

or blood may drain from the ear. Bruises may develop behind the ear (Battle's sign) or around the

eyes (raccoon's eyes). Blood may collect in the sinuses, and seizures may occur soon after the

injury or later (Head Injury).

Care for skull and facial fractures includes maintaining an open airway, immobilizing the

neck and spine, and treating wounds. Be aware of the patient's change in level of consciousness

before the arrival of medical help as these observations may help in the diagnosis of the extent of

the injury. In people with multiple injuries always assume that there is an associated spinal

injury. There may be no signs of an obvious fracture, but you must always suspect brain injury.

The presence of a head injury is the strongest independent risk factor for injury of the cervical

spine. Keep a close eye on the person's airway since the incidence of vomiting is higher in

people with brain injury. If this happens, roll the person's head, neck, and torso as a unit in case

cervical injury is present—this will avoid creating a spinal cord lesion (Head Injury in Adults).

Many skull fractures do not require surgery. A simple skull fracture requires only

observation for neurological injury. Any neurological abnormality, or abnormal finding on CT

scan, requires neurosurgical consultation. Depressed skull fractures are an exception. In this type

of fracture, one or more fragments of bone may press inward on the brain, damaging the brain. If

the depressed fracture is more than about 1/2 the skull thickness, are usually elevated in the
operating room . The brain may become exposed to the outside environment in some instances.

Open skull fractures require consultation to rule out intracranial contamination. To prevent

infection and the formation of abscesses, doctors remove foreign materials and dead tissue and

repair as much of the damage as possible. Similar to a depressed fracture the doctor’s will lift

skull fragments back into position and stitch the wound closed (Head Injury, Skull Fracture).

After treatment of a skull fracture, even those with mild head injuries, may take a

surprisingly long time to recover fully. There may be many weeks of headache, dizziness,

tiredness, loss of concentration and depression, a condition called post-concussion syndrome.

Many patients do not seek help for this. Their work, school, and home life suffer as many people

around them do not understand why a patient who appears normal is not functioning normally.

The condition always goes away, but may last for 6 months (Skull Fracture). Survivors of severe

injury tend to fare worse. Some will never recover enough to leave hospital. Those who do may

find a new disability that they need to cope with. A few will suffer from epilepsy, and even the

ones who appear to have recovered totally may have a personality change, with loss of memory,

reduced intellect and a short temper (Head Injury in Adults).

Preventing skull fractures is best seen when the proper equipment and safety gear, that is

the correct size and fits well, is used. It is a good idea to wear helmets for baseball, softball,

bicycle riding, hockey, in-line skating or riding scooters and skateboards. Protective equipment

should be approved by the organizations that govern each of the sports. Bicycle helmets should

have a safety certification sticker from the Consumer Product Safety Commission (CPSC). Also,

all equipment should be properly maintained to ensure its effectiveness (Qureshi).

 Works Cited

"Head Injury in Adults." Everyday Health. 25 Nov. 2005. Harvard Medical School. 04 Apr. 2007

<http://www.everydayhealth.com/publicsite/index.aspx>.

"Head Injury." University of Virginia Health System. 22 Jan. 2007. University of Virginia. 04 Apr. 2007

<http://www.healthsystem.virginia.edu/uvahealth/adult_neuro/headinj.cfm>.

Qureshi, Nazer H. "Skull Fracture." Emedicine. 13 Apr. 2006. University of Arkansas for Medical

Sciences. 04 Apr. 2007 <http://www.emedicine.com/med/topic2894.htm>.

"Skull Fracture." Ohio State Medical Center. 2007. Ohio State Univeristy. 04 Apr. 2007

<http://medicalcenter.osu.edu/patientcare/healthinformation/diseasesandconditions/nervous/injur

y/>.