Contents
What is a skull fracture
Fracture of the base of the skull – This is a very severe traumatic brain injury (TBI), in which one of the bones included in the base of the skull breaks: the occipital, sphenoid, temporal or ethmoid, or several of them. The cause of such damage is usually a significant impact: it can be an accident, falling backwards from a height, a direct blow with something heavy on the head or face in the region of the lower jaw.
Skull fracture survival
Of decisive importance is how quickly and competently the first aid for a fracture is provided and hospitalization is carried out with subsequent medical measures. TBI is often accompanied by heavy bleeding, which can lead to death in the first hours after injury or cause a prolonged coma, the prognosis for which is extremely unfavorable. In this case, there is a high probability of lifelong disability, when the basic vital functions are impaired and the intellect is seriously affected.
With fractures without displacement, single cracks that do not require surgical intervention, the prognosis is relatively favorable.
The mortality rate for skull base fractures ranges from 24 to 52%, depending on the severity and complexity of the injury and its subsequent complications.
Signs and symptoms of a skull fracture
Symptoms depend on the severity, location of the fracture, and the degree of damage to brain structures. Loss of consciousness can take any form, from a brief syncope at the time of injury to a prolonged coma. Disturbances of consciousness are stronger, the more severe the damage, but with an intracranial hematoma, there may be a period of enlightenment preceding loss of consciousness, which should not be mistaken for the absence or ease of injury.
Common signs of a fracture include:
Bursting headaches due to developing cerebral edema;
Vomiting, aspiration of vomit, or spontaneous leakage of stomach contents into the lungs;
Symmetrical bilateral hemorrhages around the eyes in the form of “glasses”;
Different diameter and lack of reaction of pupils;
Respiratory and circulatory disorders in case of compression of the brain stem;
The outflow of liquor (cerebrospinal fluid), mixed with blood, from the nose and (or) ears;
Cardiac disorders: arrhythmia, tachycardia, bradycardia, high or low blood pressure;
Excitation or immobility;
confusion;
Involuntary urination.
Fractures of the pyramid of the temporal bone can be longitudinal, transverse, diagonal. With longitudinal fractures, the middle and inner ear and the canal of the facial nerve are affected. Symptoms: bleeding from the ear and the release of cerebrospinal fluid due to rupture of the eardrum, hemorrhage in the area of the temporal muscle and behind the ear, partial hearing loss. Bleeding intensifies when turning the head, so this is strictly prohibited.
A transverse fracture of the temporal bone is characterized by complete hearing loss, disturbances in the functioning of the vestibular apparatus, paralysis of the facial nerve, loss of taste sensations.
Clinical signs of a fracture of the anterior fossa: epistaxis, nasal liquorrhea (cerebrospinal fluid discharge through the nose), hemorrhages around the orbits and under the conjunctiva. Bruises appear 2-3 days after the injury, which fundamentally distinguishes them from ordinary bruises that appear as a result of direct blows to the face. Sometimes there is a so-called subcutaneous emphysema: when the cells of the ethmoid bone are damaged, air penetrates into the subcutaneous tissue, which causes blisters to form on the skin.
Clinical signs of a fracture of the middle cranial fossa: unilateral ear bleeding; severe hearing loss or complete deafness; the release of cerebrospinal fluid due to rupture of the eardrum, dysfunction of the facial nerve, bruising in the area of the temporal muscle and behind the ear; partial loss of taste. Middle fossa fractures account for 70% of skull base injuries.
Clinical signs of a fracture of the posterior cranial fossa: simultaneous damage to the auditory, facial and abducent nerves; bruising behind the ears on one or both sides; when the caudal nerves are pinched or ruptured, the tongue, palate, and larynx are paralyzed and the functioning of vital organs is disrupted.
For skull base fractures lesions of the olfactory or optic nerve are also characteristic. With such fractures, a rupture of the meninges occurs, as a result of which a communication channel between the medulla and the external environment is formed through the nasal and oral cavities, middle ear or orbit. Fragmentation fractures are especially dangerous in this regard: bone fragments can injure arteries and veins. Communication with the external environment leaves the brain open to infection and germs and can lead to the development of encephalitis, meningitis, or brain abscess.
First aid for a skull fracture
If you suspect a fracture, you should immediately call an ambulance. If the condition of the victim is satisfactory and he is conscious, then he should be laid on his back (without a pillow), immobilize and fix the head and upper body, apply an antiseptic bandage to the wound. If hospitalization is delayed, dry ice may be applied to the head. If there are no breathing problems, you can give the victim Diphenhydramine or Analgin.
In an unconscious state, the victim should be laid on his back in a half-turn position and slightly turn his head to the side in order to avoid aspiration in case of vomiting, unfasten tight clothes, remove existing glasses, dentures, jewelry. To fix the body under one side of the body, put a roller of clothes or a blanket.
In acute respiratory disorders, artificial respiration is done through a mask. Cardiovascular drugs (sulfocamphocaine, cordiamine), glucose solution, lasix are introduced. With heavy bleeding and a sharp drop in pressure, Lasix is replaced by intravenous administration of polyglucin or gelatinol. With motor excitation, a solution of suprastin is injected intramuscularly.
Painkillers should be used with caution, as this can complicate bleeding. The use of narcotic painkillers is contraindicated, they exacerbate respiratory disorders.
Classification of skull base fractures
Fractures vary:
According to the damaged bones of the same name;
Along the cranial fossae of the inner surface of the skull: anterior, middle and posterior;
In relation to the external environment;
By the presence or absence of bone displacement.
The occipital and sphenoid bones are part of the brain region of the skull. The temporal bones form the vault of the skull and contain the organs of hearing: in the pyramid of the temporal bone is the tympanic cavity and the inner ear. The anterior fossa is formed by the frontal bone, a plate of the ethmoid bone, separated from the middle one by the edges of the sphenoid bone. The middle fossa is formed by the sphenoid and temporal bones. The posterior fossa is formed by the occipital bone, the posterior part of the sphenoid bone.
Non-displaced fractures are classified as open head injuries and have a favorable prognosis. If the fracture is accompanied by blood loss or leakage of cerebrospinal fluid, it is considered an open penetrating TBI.
Skull fracture treatment
Magnetic resonance imaging (MRI) or computed tomography (CT) is used to diagnose an injury accurately and in detail. Depending on the severity and complexity of the injury, treatment can be conservative or surgical.
Conservative treatment
Conservative methods are indicated for mild and moderate injuries, when liquorrhea can be eliminated non-surgically.
It is necessary to observe strict bed rest, the head should be in an elevated position – this helps to reduce the release of cerebrospinal fluid. Treatment includes dehydration therapy (aimed at reducing the fluid content in the organs), for this purpose, lumbar punctures are performed every 2-3 days (taking cerebrospinal fluid from the spinal cord at the lumbar level), subarachnoid insufflations are carried out in parallel (introduction into the subarachnoid space of the spinal cord) the same amount of oxygen. Drugs that reduce the production of cerebrospinal fluid are also used.
Physical activity is limited for six months. The victim must be registered with a traumatologist and a neurologist, observed by an otolaryngologist and an ophthalmologist.
Particular attention should be paid to the prevention of intracranial complications of a purulent nature. For this purpose, sanitation of the nasopharynx, oral cavity and middle ear is carried out with the use of antibiotics. In the presence of purulent complications, intramuscular or intravenous injections are supplemented by the introduction of antibiotics into the epidural space (endolumbar). Best of all, the selection of the drug is carried out by sowing on the flora of the cerebrospinal fluid or a smear taken from the nasal mucosa.
Surgery
Surgery is necessary in the following cases:
Identification of a multi-comminuted fracture;
Damage or compression of brain structures;
Cerebrospinal fluid leakage through the nose, which cannot be stopped by conservative methods;
Relapses of purulent complications.
Surgical treatment is used in the presence of bleeding, hematoma or bone fragments, which can pose a direct threat to life. In this case, a trepanation (opening) of the skull is performed, and after the operation, the bone tissue defect is closed with a removed bone or a special plate (in most cases). This is followed by a long recovery.
Consequences of a skull fracture
The consequences of fractures can be direct, directly occurring at the time of injury, and remote. Direct consequences include:
Intracerebral hematomas – since a fracture of the base of the skull is the result of a strong blow to the head, it is accompanied by a concussion of the brain and rupture of small, and in some cases larger blood vessels. Small hematomas can resolve themselves, large hematomas require surgical intervention, because, being in the cranial cavity, they put pressure on the surrounding tissues and disrupt the brain;
Infectious processes – if the integrity of the skull bones is violated, there is a high probability of pathogenic bacteria entering the wound, which leads to the development of inflammatory diseases such as meningitis, encephalitis, etc .;
Damage to the medulla – with a comminuted fracture, bone fragments can damage the tissues and membranes of the brain, resulting in loss of hearing or vision, as well as respiratory problems.
Long-term effects occur after a certain period of time after the recovery of the victim, most often for a period of several months to five years. Their cause is incomplete regeneration of damaged nervous tissue, as well as the formation of scars at the fracture site, which leads to compression of the nerves and small vessels that feed the brain.
Long-term consequences can be:
Paralysis and paresis;
Encephalopathy and mental disorders, from partial disorientation in space to loss of self-care skills;
epileptic seizures;
Severe cerebral hypertension, which is prone to a malignant course, can provoke a stroke and is difficult to treat.