0:00

Another indication for surgical intervention

0:03

is on the basis of a skull fracture.

0:06

It is said that patients who have open skull

0:09

fractures are generally treated surgically.

0:12

This is because open skull fractures lead from the outside

0:16

to the intracranial contents where there is CSF,

0:20

and that puts the patient at increased risk of meningitis.

0:24

So for these patients,

0:26

often, the surgeons will intervene early.

0:29

The other determination about whether or not a patient

0:33

will be operated on for skull fracture is related

0:37

to the degree of depression of the fracture.

0:41

So if we have a portion of the fracture,

0:46

which is depressed by less than one

0:49

full thickness of the bone,

0:51

those patients are often observed and don't

0:54

have intervention.

0:55

On the other hand,

0:56

if you have a fracture which is depressed greater

1:00

than one full thickness of the skull,

1:05

those patients get intervention early.

1:09

So, more than one full thickness of the skull depression

1:13

is one of the indications for surgical intervention.

1:18

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

1:22

not open to the outside world,

1:25

that is less than one full thickness depressed,

1:29

may be observed over the course of time.

1:32

Here are a couple of examples of fractures,

1:37

and I show these as two different cases.

1:41

The one above versus the one below.

1:44

As we can see by the case above,

1:47

you have a laceration through the skin surface and that

1:51

is communicating with the intracranial content.

1:54

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

1:57

one that they would intervene early in order

1:59

to prevent the possibility of meningitis.

2:02

The example below is a patient who has a depressed skull

2:06

fracture and we note that it is depressed inward by

2:10

greater than one full thickness of the adjacent temporal bone.

2:15

And therefore, because of this degree of depression,

2:19

this patient also would have intervention for

2:23

correction of the depressed skull fracture.

2:26

Interestingly enough,

2:27

you'll note that despite that great depression of the

2:30

fracture, you don't see intraparenchymal hemorrhage.

2:34

Usually there is some element of subarachnoid hemorrhage

2:38

due to some venous bleeding in the subarachnoid space,

2:43

but at least in this case,

2:45

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

2:49

It's true that in children who have more flexible

2:53

calvarium than adult calvarium, you often will see that

2:59

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

3:03

the adult where you usually will see something

3:05

underlying the fracture.

3:07

Remember that these are both coup injuries,

3:11

so do not forget to look across the aisle here,

3:15

bipartisan,

3:16

and see whether or not there is an injury

3:19

to the adjacent contrecoup location.