Head Flashcards
skull “base” comprises of:
frontal occiput occipital condyles clivus carotid canals petrous portion of temporal bones posterior sphenoid wall
basically a linear fracture of the skull base
basilar skull fracture
Trauma resulting in fractures to this area typically does not have localizing symptoms.
basilar skull fracture
basilar skull fracture
Indirect signs of the injury
Battle sign or “raccoon eyes.”
Hemotympanum
blood in the sphenoid sinus
Clear or pink rhinorrhea - dextrose stick test (+), filter paper (halo or double ring)
visible evidence of bleeding from the basilar fracture into surrounding soft tissue
Battle sign or “raccoon eyes.”
Bleeding into other structures from basilar fracture—includes
hemotympanum
blood in the sphenoid sinus
seen as an air-fluid level on computed tomography (CT)
hemotympanum
blood in the sphenoid sinus
clear or pink rhinorrhea
can indicate
Cerebrospinal fluid (CSF) leaks
how to confirm that
clear or pink rhinorrhea
is associated with CSF leaks
dextrose stick test (+)
filter paper - halo or double ring
Identify underlying brain injury, which is best accomplished by
CT
also the best diagnostic tool for identifying the fracture site, but fractures may not always be evident.
CT
Evidence of open communication, such as a CSF leak, mandates
neurosurgical consultation and admission
are antibiotics recommended in CSF leak
controversial because of the possibility of selecting resistant organisms.
Clinical manifestations of basilar skull fracture may take_______ to fully develop.
several hours
indications for head CT
and threshold
low threshold for head CT in any patient with head trauma, loss of consciousness, change in mental status, severe headache, visual changes, or nausea or vomiting.
The use of filter paper or a dextrose stick test to determine if CSF is present in rhinorrhea is______% reliable.
not 100% reliable
Acute periorbital ecchymosis seen in this patient with a basilar skull fracture. These findings may also be caused by facial fractures
Raccoon Eyes
Subtle periorbital ecchymosis manifests 1 hour after a blast injury
early raccoon eyes
Seen in a basilar skull fracture when the fracture line communicates with the auditory canal, resulting in bleeding into the middle ear
hemotympanum
Blood can be seen behind the tympanic membrane
Depressed skull fractures typically occur when
a large force is applied over a small area.
when are Depressed skull fractures classified as open
skin above them is lacerated
sx that may also be present over the fracture site
Depressed skull fractures
Abrasions, contusions, and hematomas
mental status changes - dependent upon the degree of underlying brain injury
evidence of basilar fracture, facial fractures, or cervical spinal injuries
how to manage depressed skull fractures
- Explore all scalp lacerations to exclude a depressed fracture
- CT - determine the extent of underlying brain injury
- immediate neurosurgical consultation
- Open fractures -antibiotics and tetanus prophylaxis as indicated
- decision to observe or operate - made by neurosurgeon
Children below 2 years of age with skull fractures can develop
leptomeningeal cysts, which are extrusion of CSF or brain through dural defects
-> children below age 2 with skull fractures require close follow-up or admission
Examine all scalp injuries including lacerations for evidence of fractures or depression. When fragments are depressed _____ mm below the inner table, penetration of the dura and injury to the cortex are more likely.
5 mm
Children with depressed skull fractures are more likely to develop
epilepsy
Ping pong ball skull fractures can occur from a
forceps delivery or from compression by mother’s sacral promontory during delivery.
Patients with head injuries must be evaluated for
cervical spine injuries.
Akin to the greenstick fracture, occurs when a newborn or infant’s relatively soft skull is indented by the corner of a table or similar object without causing a frank break in the bone
Ping pong ball skull fractures
Scalp lacerations should undergo
sterile exploration for skull fracture
Clinically significant nasal fractures are almost always evident with
deformity, swelling, and ecchymosis
Epistaxis in nasal fractures may be due to
septal or turbinate laceration but can also be seen with fractures of adjacent bones, including the cribriform plate
is a rare but important complication that, if untreated, may result in necrosis of the septal cartilage
Septal hematoma
Septal hematoma may lead to this deformity
saddle-nose” deformity.
has nasal or frontal crepitus and may have telecanthus or obstruction of the nasolacrimal duct.
frontonasoethmoid fracture
Management nasal fractures
- Look for more serious injuries first.
- CT to rule out facial fractures.
- Refer obvious deformities within 2 to 5 days for reduction, after the swelling has subsided
- Simple nasal fracture - vigorously irrigate + suture lacerations + antibiotic coverage
Nasal fractures with mild angulation and without displacement may be reduced in the
emergency department (ED)
Nasal injuries without deformity
need only conservative therapy with an analgesic and possibly a nasal decongestant
septal hematomas on nasal fractures
Immediately drain
with packing placed to prevent reaccumulation
Uncontrolled epistaxis on nasal fractures
intervention
require nasal packing
for nasal fractures
to perform a good intranasal examination
control epistaxis
If obvious deformity is present, including a new septal deviation or deformity, treat with
ice and analgesics and provide ENT referral in 2 to 5 days for reduction.
patients discharged with nasal packing should be placed on
antistaphylococcal antibiotics and referred to ENT in 2 to 3 days
Although the effectiveness of prophylactic antibiotics to prevent toxic shock syndrome is unproven
Consider cribriform plate fractures in patients after nasal injury if they present with
clear rhinorrhea
Patients with facial trauma should be examined for a
septal hematoma
bluish, grapelike mass on the nasal septum
septal hematoma
septal hematoma
tx
incision, drainage, and packing
The zygoma bone has two major components
zygomatic arch and the body.
forms the inferior and lateral orbit
arch
forms the malar eminence of the face
body
Direct blows to the arch can result in
isolated arch fractures
isolated arch fractures
manifestations
pain on opening the mouth
secondary to the insertion of the temporalis muscle at the arch or
impingement on the coronoid process
More extensive trauma to the zygomatic arch can result in the
tripod fracture
tripod fracture
consists of fractures through three structures: the frontozygomatic suture;
the maxillary process of the zygoma including the inferior orbital floor, inferior orbital rim, and lateral wall of the maxillary sinus; and
the zygomatic arch
tripod fracture
present with
flattened malar eminence and edema and ecchymosis to the area, with a palpable step-off on examination
infraorbital paresthesia
gaze disturbances
Subcutaneous emphysema
What other structures that can be affected by zygomatic fracture
Injury to the infraorbital nerve may result in infraorbital paresthesia
disturbances may result from injury to orbital contents
imaging that best identifies zygoma fractures
Maxillofacial CT
Treat simple zygomatic arch or tripod fractures without eye injury with
ice and analgesics and refer for delayed operative consideration in 5 to 7 days.
when should you urgently refer zygoma fractured
extensive tripod fractures or those with eye injuries
intervention
refer urgently
Decongestants and broad-spectrum antibiotics - since the fracture crosses into the maxillary sinus
Zygoma Fractures with blood in the sinus should also be treated with
antibiotics
