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Surgical Indications of Skull Fractures

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Another indication for surgical intervention

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is on the basis of a skull fracture.

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It is said that patients who have open skull

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fractures are generally treated surgically.

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This is because open skull fractures lead from the outside

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to the intracranial contents where there is CSF,

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and that puts the patient at increased risk of meningitis.

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So for these patients,

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often, the surgeons will intervene early.

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The other determination about whether or not a patient

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will be operated on for skull fracture is related

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to the degree of depression of the fracture.

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So if we have a portion of the fracture,

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which is depressed by less than one

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full thickness of the bone,

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those patients are often observed and don't

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have intervention.

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On the other hand,

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if you have a fracture which is depressed greater

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than one full thickness of the skull,

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those patients get intervention early.

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So, more than one full thickness of the skull depression

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is one of the indications for surgical intervention.

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However, a closed fracture that is not open to the air,

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not open to the outside world,

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that is less than one full thickness depressed,

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may be observed over the course of time.

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Here are a couple of examples of fractures,

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and I show these as two different cases.

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The one above versus the one below.

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As we can see by the case above,

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you have a laceration through the skin surface and that

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is communicating with the intracranial content.

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So this is what we would call an open fracture and this is

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one that they would intervene early in order

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to prevent the possibility of meningitis.

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The example below is a patient who has a depressed skull

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fracture and we note that it is depressed inward by

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greater than one full thickness of the adjacent temporal bone.

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And therefore, because of this degree of depression,

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this patient also would have intervention for

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correction of the depressed skull fracture.

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Interestingly enough,

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you'll note that despite that great depression of the

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fracture, you don't see intraparenchymal hemorrhage.

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Usually there is some element of subarachnoid hemorrhage

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due to some venous bleeding in the subarachnoid space,

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but at least in this case,

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you don't see anything in the brain parenchyma per se.

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It's true that in children who have more flexible

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calvarium than adult calvarium, you often will see that

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they don't have adjacent brain tissue damage as opposed to in

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the adult where you usually will see something

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underlying the fracture.

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Remember that these are both coup injuries,

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so do not forget to look across the aisle here,

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bipartisan,

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and see whether or not there is an injury

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to the adjacent contrecoup location.

Report

Description

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Vascular

Trauma

Temporal bone

Neuroradiology

Musculoskeletal (MSK)

Interventional

Infectious

Emergency

CT

Brain

Bone & Soft Tissues

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