Skull Fractures

Question 1

how do skull fractures occur?

Answer 1

when forces striking the head exceed the mechanical integrity of the skull

Question 2

Skull Fractures

which bone is most likely to fracture? next 3 most likely?

Answer 2

1. parietal
2. temporal, occipital, frontal

Question 3

Skull Fractures

most common fracture type? next 2 most likely?

Answer 3

1. linear
2. depressed, basilar

Question 4

Skull Fractures

most common causes of head injuries

Answer 4

• falls
• assaults
• MVCs
• penetrating missiles

Question 5

Skull Fractures

bones of the skull

Answer 5

• frontal
• ethmoid
• sphenoid
• occiptal
• 2 parietal
• 2 temporal

Question 6

Skull Fractures

avg thickness of bones in adults

Answer 6

2-6mm
temporal region is the thinnest

Question 7

Skull Fractures

immbolize what with any skull fracture associated w/ head injury?

Answer 7

c-spine and t-spine

Question 8

Skull Fractures

what to do when pt arrives to ER w/ skull fracture

3

Answer 8

1. identify & stabilize life threatening injuries
2. protect and stabilize airway
3. then assess for: altered mental status, focal neurologic deficits, scalp lacerations, bony step off, periorbital or retroauricular ecchymosis

Question 9

Skull Fractures

what should you not do to scalp wounds?

Answer 9

probe them

Question 10

Skull Fractures

dx

Answer 10

• non-contrasted CT
• MRI if suspecting vascular or ligament injury
• NO BENEFIT of skull x rays

Question 11

Skull Fractures

dx if basilar fracture is suspected

Answer 11

• CT angiography to assess for vascular injury

Question 12

Linear Skull Fractures

describe this fracture type

Answer 12

single fracture that extends through the entire thickness of the skull

Question 13

Linear Skull Fractures

most often involve which bones?

Answer 13

• temporoparietal
• frontal
• occipital

Question 14

Linear Skull Fractures

clinical significance

Answer 14

minimal!

Question 15

Linear Skull Fractures

when is there clinical significance?

Answer 15

• if the linear fracture crosses the middle meningeal groove in the temporal bone or major venous sinuses

Question 16

Linear Skull Fractures

why is it worrying if the linear fracture crosses the middle meningeal groove or major venous dural sinuses?

Answer 16

• can cause significant extra axial bleeding (beneath the skull but outside the brain parenchyma)

Question 17

Linear Skull Fractures

common presentation

Answer 17

• if simple + closed: no neurologic sx
• can have swelling over fracture site

Question 18

Linear Skull Fractures

a minority of these patients develop what?

Answer 18

ICH

Question 19

Linear Skull Fractures

management

4 components

Answer 19

• no specific intervention necessary if CT reveals no underlying brain injury or depressed fracture
• emergent neuro consult if ICH
• neuro checks
• can observe in ED or admit for monitoring

Question 20

Depressed Skull Fractures

how to these occur?

Answer 20

• occur when trauma drive a segment of skull below the level of the adjacent skull

Question 21

Depressed Skull Fractures

often involve injury to the?

Answer 21

brain parenchyma

Question 22

Depressed Skull Fractures

complications

3

Answer 22

1. CNS infection
2. seizure
3. death

Question 23

Depressed Skull Fractures

what can you do but must be very careful?

Answer 23

palpate the depression! (often limited due to swelling)

Question 24

Depressed Skull Fractures

DO NOT do what

Answer 24

blindly probe the wound

Question 25

# Depressed Skull Fractures management

Answer 25

* Prophylactic meds due to increased risk of infection (tetnus, abx, anti-convulsants) * admission (enruosurgery or non-operative management)

Question 26

# Depressed Skull Fractures when to send to OR

Answer 26

* depressed more than the thickness of the skull

Question 27

# Depressed Skull Fractures when to manage non-operatively

Answer 27

* no evidence of dural penetrations or complication on CT * if fracture is closed

Question 28

# Basilar Skull Fractures involve at least one what five bones? | 5

Answer 28

* cribiform plate of ethmoid bone * orbital plate of frontal bone * petrous and squamous portion of temporal bone * sphenoid bone * occipital bone

Question 29

# Basilar Skull Fractures most commonly occur through what bone?

Answer 29

temporal

Question 30

# Basilar Skull Fractures suspect what if temporal bone is involved?

Answer 30

epidural hematoma

Question 31

# Basilar Skull Fractures what artery/vein is the temporal bone located near?

Answer 31

* middle meningeal artery/vein

Question 32

# Basilar Skull Fractures clinical signs | 8

Answer 32

1. periorbital ecchymosis (raccoon eyes) 2. retroauricular ecchymosis (Battle's sign) 3. otorrhea (CSF leak from ear) 4. rhinorrhea (CSF lead from nose) 5. hemotypanum (blood behind TM in ear) 6. Neurologic presentation (depends on location) 7. CN deficits depending on location 8. dural tear

Question 33

# Basilar Skull Fractures rare but significant complication

Answer 33

traumatic carotid cavernous fistula

Question 34

# Basilar Skull Fractures Management

Answer 34

* surgical emergency if ICH * admit for observation (EVERYONE) * close neuro monitoring * CSF leaks should self resolve * glucocorticoids for CN palsies

Question 35

# Elevated Skull Fracture occur when?

Answer 35

the fracture fragment is elevated above the underlying skull

Question 36

# Elevated Skull Fracture which bone most commonly affected?

Answer 36

frontal

Question 37

# Elevated Skull Fracture associated with?

Answer 37

significant intracranial injury

Question 38

# Elevated Skull Fracture usually blank rather than blank

Answer 38

* tangental * perpendicular

Question 39

# Penetrating Skull Fracture results of?

Answer 39

* gun shots * stab wounds * blast injuries

Question 40

# Penetrating Skull Fracture complications? | 2

Answer 40

* significant brain injury * significant brain hemorrhage

Question 41

# Anti-Coagulated Pts what are pts on warfarin or clopidogrel at high risk of?

Answer 41

ICH

Question 42

# Anti-Coagulated Pts what to do with these pts regardless of skull fracture type?

Answer 42

admit for observation

Question 43

# Anti-Coagulated Pts what to do at first sign of neurologic deterioration

Answer 43

STAT non-contrasted CT of the head

Question 44

# Anti-Coagulated Pts what could you consider?

Answer 44

reversal of anti-coag status