0:00

This is the same 9-year-old patient

0:03

who I demonstrated previously,

0:05

who had the posterior fossa hemorrhage.

0:08

However,

0:09

I want to look at the bone windows to show you

0:11

the calvarial changes in this individual.

0:14

So, as you can see,

0:16

this patient has soft tissue swelling,

0:19

as well as some air in the subcutaneous tissue,

0:22

likely from a laceration or puncture wound.

0:27

However, you'll also note, as I scroll,

0:29

that the patient has a small area of dark signal intensity

0:32

along the calvarium,

0:33

representing pneumocephalus.

0:36

Let me demonstrate that.

0:37

So this is the area of the pneumocephalus demonstrated,

0:42

and you can see the soft tissue swelling

0:44

with the air more superficially.

0:47

What I want to point out, however, is this area here

0:50

where the patient has a calvarial fracture.

0:54

Let's scroll through that.

0:56

As we move through, you can see that,

0:58

in point of fact, this is a comminuted fracture.

1:01

There's a portion here more posteriorly and a portion

1:05

here more anteriorly.

1:06

You'll note that this fracture,

1:08

although depressed,

1:09

is not depressed by greater than one calvarial thickness.

1:14

It's only about, let's say, 25% to 30%.

1:17

And therefore, this in and of itself,

1:20

were it not for the open wound,

1:22

which we demonstrated shortly,

1:24

would not be treated surgically.

1:27

You'll notice, however,

1:28

that the patient does have another fracture on

1:30

the contralateral side.

1:31

This one as well is nondisplaced

1:35

and would not otherwise be treated surgically.

1:38

As we scroll further inferiorly,

1:40

we see that the degree of the displacement of the anterior

1:44

portion of this fracture is increasing over

1:47

the course of inferior scrolling.

1:50

And eventually, you see that we have this comminuted

1:54

area with air adjacent to the fracture,

1:58

and then some fracture fragments

2:00

that are depressed greater than

2:03

one skull thickness deep,

2:06

and these would have to be treated neurosurgically.

2:09

This is the same patient before who had that fracture

2:12

through the mastoid portion of the temporal bone

2:15

with extension to the middle ear cavity.

2:18

So, again,

2:19

the indications for surgery include an open fracture,

2:22

which is communicating with the outer surface of the skin,

2:28

leading to the high rate of possible meningitis,

2:31

as well as the degree of depression

2:34

greater than one skull thickness deep.