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. Adepressed 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 allowsa 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 cribriformplate and the frontal sinuses. Because of the danger of cranial nerve complications, dural tears, and meningitis, basilar fractures usually are far more serious thanvault fractures.
Like concussions and cerebral contusions or lacerations, skull fractures invariably result from a traumatic blow to the head. Motor vehicle crashes, bad falls, andsevere beatings (especially in children and elderly people) top the list of causes.
Skull fractures can lead to infection, intracerebral hemorrhage and hematoma, brain abscess, and increased intracranial pressure (ICP) from edema. A linear fractureacross a suture line in an infant increases the possibility of epidural hematoma.Recovery from the injury can be complicated by the residual effects of the injury, such as seizure disorders, hydrocephalus, and organic brain syndrome.
The patient’s history—obtained from the patient, family members, eyewitnesses, or emergency personnel—reveals a traumatic injury to the skull. The patient mayhave lost consciousness and developed other neurologic changes. If conscious, he may complain of a persistent, localized headache. Assessment may reveal decreased pulse and respiratory rates as well as labored respirations. On inspection, a conscious patient with a linear fracture and aconcussion may appear dazed. If he has another type of skull fracture, he may appear anxious and, depending on his neurologic status, may have normal responsesor appear agitated and irritable.Because scalp wounds commonly accompany skull fractures, inspection of the scalp may reveal abrasions, contusions, lacerations, or avulsions. If the scalp waslacerated or torn away, you may note profuse bleeding. The patient, however, may be in shock from other injuries or from medullary failure if the head injury is severe.You’ll also note swelling and ecchymosis in the area of the injury, a sign that a fracture has occurred.Other findings on inspection may include bleeding in the nose, pharynx, or ears; under the conjunctivae; under the periorbital skin (raccoon’s eyes); and behind theeardrum. You may also observe Battle’s sign (postauricular ecchymosis).Inspection of the ears and nose may reveal cerebrospinal fluid (CSF) and brain tissue leakage. The halo sign—a blood-tinged spot surrounded by a lighter ringcaused by leakage of CSF—may also appear on the patient’s pillowcase or bed linens.Palpation of the head may reveal palpable fractures, areas of swelling and, possibly, hematoma. A vault fracture commonly causes soft-tissue swelling near the site,which makes the fracture difficult to detect without X-rays.During your neurologic assessment, you may observe altered level of consciousness (LOC) along with other classic signs and symptoms of brain injury. Theseinclude agitation and irritability, abnormal deep tendon reflexes, altered pupillary and motor responses, hemiparesis, dizziness, seizures, and projectile vomiting. Lossof consciousness may last for hours, days, weeks, or indefinitely. Keep in mind that linear fractures associated only with concussion don’t produce loss ofconsciousness.Your neurologic assessment also may reveal vision loss in a patient with a sphenoidal fracture, and unilateral hearing loss or facial paralysis in a patient with atemporal fracture.
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 CSFin nasal or ear drainage. Cerebral angiography locates vascular disruptions from internal pressure or injury. Magnetic resonance imaging, a CT scan, and a radioisotope scan discloseintracranial 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 thepatient’s coagulation time if he’s taking anticoagulants at home. An increased International Normalized Ratio (INR) may necessitate treatment with fresh frozenplasma.If the patient hasn’t lost consciousness, he should be observed in the emergency department for at least 4 hours. After this period, a patient with stable vital signs canbe discharged. He should receive an instruction sheet for 24 to 48 hours of observation at home. More severe vault fractures, especially depressed fractures, usually require a craniotomy to elevate or remove fragments that have been driven into the brain and toextract foreign bodies and necrotic tissue. This reduces the risk of infection and further brain damage.
Cranioplasty follows the use of tantalum mesh or acrylic platesto replace the removed skull section. The patient commonly requires antibiotics, tetanus prophylaxis, and (in profound hemorrhage) blood transfusions. The patientmay require sedating medication, such as Ativan (lorazepam) to help reduce seizures, or an anticonvulsant may be required.For status epilepticus, the patient may receive an anticonvulsant, usually 10 to 15 mg/kg of I.V. phenytoin sodium administered at a rate of not more than 50mg/minute. A maintenance dose should then be ordered to prevent the recurrence of seizures.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 I.V. or I.M. dexamethasone to reducecerebral edema and minimize brain tissue damage.