Head Injuries

Question 1

Types of head injuries

Answer 1

1- Scalp wounds.
2- Skull fracture.
3- Meningeal injuries.
4- Brain injuries.

Question 2

1- Scalp wounds

Answer 2

Cut and Contused wounds of scalp. (BOTH have REGULAR edges and show free BLENDING).

• BRUISES around the edges and TISSUE BRIDGES in Contused wounds.
• CRUSHED hair tip in contused and SHARP CUT in cut wounds.

Question 3

2- types of Skull fractures (injuries)

Answer 3

A-Fissure fracture.
B-Depressed fracture.
C-Comminuted fracture.
D-Cut fracture.

Question 4

Causative instrument of Fissure fracture

Answer 4

• Heavy blunt object with MODERATE or WIDE striking surface and LOW momentum e.g. Stick

Question 5

Characters of Fissure fracture

Answer 5

-Beginning: at site of impact and widest at this point of impact (EXCEPT in Polar fracture)
-Course: linear along the anatomical weakness.
-End: may extend to Base of skull as:
•Frontal fracture (RTA) > anterior cranial fossa. [CSF RHINORRHEA and RACON EYES]
•Temporal fracture (blow to side of head) > middle cranial fossa. [CSF ORORRHEA]
•Occipital fracture (backward fall) > posterior cranial fossa.

Question 6

DDx of Black eye:

Answer 6

• Direct blow. (Unilateral)
• Gravitational (from bruises above eyebrow).
• Anterior cranial fracture (passage of blood into orbit) BILATERAL.

Question 7

Special types of Fissure fracture

Answer 7

1-Diastatic fracture: passing in NON-UNITED suture causing SEPARATION of bones.
2-Polar fracture: at BUGLING POLES MIDWAY between striking point and supported point.
3-Ring fracture: around FORAMEN MAGNUM due to fall from hight on FEET or buttocks.

Question 8

Causative instrument of Depressed fracture:

Answer 8

Heavy blunt object with LOCALIZED striking surface and MODERATE momentum e.g. Head of HAMMER.

Question 9

Characters of Depressed fracture

Answer 9

• Takes SHAPE of striking surface (rounded, square, triangular)
• More DRIVEN INWARD in one part which is nearer to Assailant.
• In Children elastic bone do not fracture > CONCAVE depression (Pond fracture).

Question 10

Causative instrument of Comminuted fracture

Answer 10

Heavy blunt object with WIDE striking surface and HIGH momentum e.g. Fall from hight or car accidents.

Question 11

Causative instrument of Cut fracture

Answer 11

Heavy SHARP object with MODERATE momentum e.g. Axe and chopper.

Question 12

Characters of Cut fracture

Answer 12

• Regular, straight and sharply cut edges.

- Maybe Triangular if striking with Axe angle the BASE nearer to Assailant.

Question 13

Healing of Skull fracture

Answer 13

•Fissures: -COMPLETELY united in 3 months unless edges separated by tissue.
•Skull defects: as in (Trephine operation):
-Bones of vertex NEVER fills with bone (membranous in origin) > permanent infirmity.
-The membrane starts to appear after 3 months and fills the defect in 12 months.

Question 14

3-Types of Brain injuries:

Answer 14

A- Concussion.
B- Diffuse Axonal Injury (DAI).
C- Cerebral compression.

Question 15

Define concussion

Answer 15

A state of SUDDEN TRANSIENT loss of consciousness following head injuries due to TEMPORARY arrest of brain functions with NO VISIBLE physical damage .

Question 16

Mechanisms of concussion

Answer 16

VIBRATION affecting reticular formation in the brain stem

Question 17

Clinical picture of concussion

Answer 17

1- SUDDEN and TRANSIENT loss of consciousness >6H .
2- post traumatic amnesia.
3- signs of shock ( rapid week pulse + low BP+ low temperature)

Question 18

Treatment of concussion

Answer 18

Patient sholud be HOSPITALIZED under observation for 48 h .

Question 19

Prognosis of concussion

Answer 19

1- complete recovery. (Most common)
2- incomplete recovery . ( post concussion syndrome for few days to few weeks)
3- fatal concussion ( rare )
4- concussion passing to compression.
a- with lucid interval. B -directly ( without lucid interval )

Question 20

Definition of lucid interval

Answer 20

Stage of consciousness between unconscious of concussion and that of compression

Question 21

Mechanisms of lucid interval

Answer 21

Fracture of temporal bone –> TEAR of MMA –> during concussion the BP is low so nothing will happen but when the patient is conscious the BP will be normal so –> MMA bleeding –> compression

Question 22

MLI of lucid interval

Answer 22

1- any patient with head trauma should be observed for at least 24-48 h if pulse decompression operation urgently .

2- the assailant defense may assume the cause of death is not head trauma.

3- victim may tell the name of assailant

Question 23

Definition of diffuse axonal injury (DAI)

Answer 23

Condition of diffuse injury of the axons of the brain associated with IMMEDIATE unconscious and coma >6h . Common on RTA ( road traffic accident)

Question 24

Definition of cerebral compression

Answer 24

A state of increased intracranial pressure (10-15 mmHg) due to several causes .

Question 25

Causes of cerebral compression

Answer 25

1-intracranial haemorrhage
2-depressed skull fractures
3-Intercranial tumours
4-infections
5-Brain oedema
6-CSF Obstruction ( hydrocephalus) or increase production ( meningitis)

Question 26

Stages of cerebral compression

Answer 26

1- IRRITATION STAGE :
Increase ICP–> occlusion of cerebral Viens –> Brain edema –> irritation.
2- PARALYTIC STAGE :
Increase ICP –> occlusion of cerebral arteries–> Ischaemia and brain infarction.
3- CONIZATION STAGE :
Increased ICP–> brainstem compression–> herniation of the medulla Through foreman Magnum –> death ( asphyxia or syncope )

Question 27

Clinical picture of traumatic cerebral compression

Answer 27

1- history of head trauma
2- gradual loss of consciousness
3-irritability or disorientation
4-persistent headache , projectile vomiting and papilledema .
5- Cushing triad ( slow fall regular pulse, hypertension and slow breathing May be irregular)
6- high temperatures.
7- sign of lateralization. ( ستوضح لاحقا )

Question 28

Sign of lateralization

Answer 28

1- contralateral hypertonia and hyperreflexia then weakness or paralysis .

2-unequal pupil size: IPSILATERAL constriction then DILATION following by constriction and dilation of the other side

Question 29

Types Intracranial hemorrhage

Answer 29

1- extradural (epidural) hemorrhage.
2-subdural hemorrhage.
3- subarachnoid hemorrhage.
4- intracerebral hemorrhage.

Question 30

Epidural (extradural) hemorrhage :
A) Always…………. .

B) Bleeder : ………… .

C )Clinical picture: ……………. .

Answer 30

A) traumatic.

B) MMA

C ) concussion –> compression with lucid interval. OR cerebral compression.

Question 31

Subdural hemorrhage

A) Usually ……………….. ( ……….) .
B) Bleeder: ………….

C ) types: …………

Answer 31

A) traumatic ( inertial trauma )

B) bridging veins .

C) 1- acute SDH : sudden jarring or rotation of head ( shaken baby syndrome) .
** CLINICALLY : concussion –> compression with or without lucid interval.
2- chronic SDH : repeated minor trauma to the head ( more common in elderly +alcoholics + diabetics )

Question 32

Subarachnoid hemorrhage 
a) mainly........
B) due to ...........
C ) common in .........
D) site of bleeding ..........

Answer 32

A ) pathological

B) rupture of congenital aneurysm

C ) in females

D ) circle of wills ( berry aneurysm)

Question 33

Intracerebral hemorrhage

A ) either1: …….. Or2: …….
B) 1: ….. Due to…….
2:…… Due to …….

Answer 33

A) pathological or traumatic

B ) 1- pathological due to hypertension and atherosclerosis of cerebral arteries usually at CORPUS STRATUM or PONS
* MALE ** 40-60 .
2- traumatic due to trauma of same side ( coup) or opposite side ( counter - coup ) usually at TEMPORAL or FRONTAL .
Any SEX or AGE .