The first concern in a skull fracture is possible damage to the brain rather than the fracture itself; therefore, the injury is considered a neurosurgical condition. Signs and symptoms reflect the severity and extent of the head injury.
Skull fractures may be simple (closed) or compound (open) and may displace bone fragments. They're also described as linear, comminuted, or depressed. A linear, or hairline, fracture doesn't displace structures and seldom requires treatment. A comminuted fracture splinters or crushes the bone into several fragments. A depressed fracture pushes the bone toward the brain; it's considered serious only if it compresses or lacerates underlying structures. A child's thin, elastic skull allows a depression without a fracture.
Skull fractures also are classified according to location, such as cranial vault or basilar. A basilar fracture occurs at the base of the skull and involves the cribriform plate and the frontal sinuses. Because of the danger of cranial nerve complications, dural tears, and meningitis, basilar fractures usually are far more serious than vault fractures.
Like concussions and cerebral contusions or lacerations, skull fractures invariably result from a traumatic blow to the head. Motor vehicle crashes, bad falls, and severe beatings (especially in children and elderly people) top the list of causes.
Symptoms of skull fractures may include headaches, confusion, persistent blurred vision, unconsciousness, amnesia or loss of memory, muscles weakness, paralysis, loss of sensation, vomiting, unequally sized pupils, double vision and even deteriorating levels of consciousness that suggest progressive brain damage.
A computed tomography (CT) scan may locate the fracture. (Cranial vault fractures aren't visible or palpable.) Reagent strips reveal the presence or absence of CSF in nasal or ear drainage. (Note: A positive result is also obtained if the patient is hyperglycemic.)
Cerebral angiography locates vascular disruptions from internal pressure or injury. Magnetic resonance imaging, a CT scan, and a radioisotope scan disclose intracranial hemorrhage from ruptured blood vessels.
Although a simple linear skull fracture can tear an underlying blood vessel or cause a CSF leak, most linear fractures require only supportive treatment. Such treatment includes mild analgesics (acetaminophen) as well as cleaning, debriding, and suturing the wound after injection of a local anesthetic. Be sure to note the patient's coagulation time if he's taking anticoagulants at home. An increased International Normalized Ratio (lNR) may necessitate treatment with fresh frozen plasma.
More severe vault fractures, especially depressed fractures, usually require a craniotomy to elevate or remove fragments that have been driven into the brain and to extract foreign bodies and necrotic tissue. This reduces the risk of infection and further brain damage. Cranioplasty follows the use of tantalum mesh or acrylic plates to replace the removed skull section. The patient commonly requires antibiotics, tetanus prophylaxis, and (in profound hemorrhage) blood transfusions. The patient may require sedating medication, such as Ativan (lorazepam) to help reduce seizures, or an anticonvulsant may be required.
A basilar fracture calls for immediate prophylactic antibiotics to prevent meningitis from CSF leaks. The patient also needs close observation for secondary hematomas and hemorrhages; surgery may be necessary. Also, a patient with either a basilar or a vault fracture requires l.V. or l.M. dexamethasone to reduce cerebral edema and minimize brain tissue damage.
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