Also see defaults disclaimers (p. 27). 1. position: (depends on location of the fracture) 2. postop: ICU 3. blood: type screen (for severe fractures: type and cross 2U PRBC) 4. consent (in lay terms for the patient not allinclusive): a) procedure: surgery in the area of the skull fracture to bone fragments that may have been dis¬placed, to repair the covering of the brain, to remove any foreign material that can be identi¬fied and any permanently damaged brain tissue (i.e. dead brain tissue), remove any blood clot and stop any bleeding identified, possible placement of intracranial pressure monitor. If a large opening has to be left in the skull, it may require surgery to correct in a number of months (3 or more) b) alternatives: nonsurgical management c) complications usual craniotomy complications (p. 28) plus any permanent brain injury that has already occurred is not likely to recover, seizures may occur (with or without the surgery), hydrocephalus, infection (including delayed infectionabscess)
Table 57.1 Feature Differentiating linear skull fractures from normal plain film findings Linear skull fracture 57 dark black density straight course Vessel groove Skull grey Fractures curving 57.1General information often branching branchin g usually none Suture line grey follows course of known suture lines joins other suture lines Classified as either thicker closed than (simplefracture) or open jagged, (compound fracture) fracture wide Diastatic fractures extend into and separate sutures More common in young children very thin width 57.2Linear skull fractures over the convexity 90%of pediatric skull fractures are linear and involve the calvaria □ Table 57.1 shows some differentiating features to distinguish linear skull fractures See also Indications for CT and admission criteria for TBI (p.830) By themselves, linear skull fractures over the convexity rarely require surgical intervention 57.3Depressed skull fractures For special considerations in pediatrics, see Depressed skull fractures (p.915) in pediatrics section 57.3.1 Indications for surgery See Practice guideline: Surgical management of depressed skull fractures (p 882) Some additional observations regarding surgery to elevate a depressed skull fracture in an adult: consider surgery for depressed skull fractures with deficit referable to underlying brain □ more conservative treatment is recommended for fractures overlying a major dural venous sinus (note:exception: depressed fractures overlying and depressing one of the dural sinuses may be dangerous to elevate, and if the patient is neurologically intact, and no indication for operation (e.g CSF leak mandates surgery) may be best managed conservatively) Practice guideline: Surgical management of depressed skull fractures Indications for surgery 57 Level HI2: open (compound) fractures a) surgery for fractures depressed >thickness of calvaria and those not meeting criteria for non- surgical management listed below b) nonsurgical management may be considered if • there is no evidence (clinical or CT) of dural penetration (CSF leak, intradural pneumocepha- lus on CT ) • and no significant intracranial hematoma • and depression is 20 (more important than the number of knock-outs) boxing style: increased risk among poorer performers, those known as sluggers rather than“scientific”boxers, those known to be hard to knockout or known to take a punch and keep going age at exam ination : long latency causes increased prevalence with age and possibly, the number of head blows • • • • • • • • risk increases in patients with the apolipoprotein E (apo E) e4 allele (as in Alzheimer's disease) as shown in □ Table 61.4 professional boxers (more risk than amateurs) Ebooksmedicine.net Neuro-imaging The most common finding is cerebral atrophy A cavum septum pellucidum (CSP) is observed in 13% of boxers.40CSP in this setting probably represents an acquired condition41and correlates with cerebral atrophy References [1] Brain Trauma Foundation, Povlishock JT, Bullock [19] MR Infection Duke JH, Jorgensen SB, Broell JR, et al Contribution of prophylaxis J Neurotrauma 2007; 24:S26-S31 Protein to Caloric Expenditure Following Injury Surgery [2] Kaufman HH, Slatterwhite T, McConnell BJ, et al [20] Deep vein 1970; 68:168-174 thrombosis and pulmonary embolism in head-injured patients Angiology Poca MA, Sahuquillo J, Mataro M, Benejam B, Arikan F, 1983; 34:627 Baguena M Ventricular enlargement after moderate or severe 638 head injury: a frequent and neglected problem J Neurotrauma [3] Brain Trauma Foundation, Povlishock JT, Bullock [21] MR Deep vein 2005; 22:1303-1310 Tian HL, Xu T, Hu J, Cui YH, Chen H, thrombosis prophylaxis J Neurotrauma 2007; 24:S32-S36 Zhou LF Risk factors related to hydrocephalus after traumatic [4] Brain Trauma Foundation, Povlishock JT, Bullock subarachnoid hemorrhage Surg Neurol 2008; 69:241MR Nutrition J Neurotrauma 2007; 24:S77-S82 [22] 6;discussion 246 [5] Clifton GL, Robertson CS, Grossman RG, et al The Metabolic Response to Marmarou A, Foda MA, Bandoh K, Yoshihara M, Yamamoto T, Severe Head Injury J Neuro- surg 1984; 60:687-696 Tsuji O, Zasler N, Ward JD, Young HF Posttraumatic [6] Young B, Ott L, Norton J, et al Metabolic and Nutritional Sequelae in the ventriculomegaly: hydrocephalus or atrophy? A new approach Non-Steroid Treated [23] Head Injury Patient Neurosurgery 1985; 17:784- for diagnosis using CSF dynamics J Neurosurg 1996; 791 85:1026-1035 [7] Deutschman CS, Konstantinides FN, Raup S, et al [24] Physiological and Miller JD, Butterworth JF, Gudeman SK, et al Further Metabolic Response to Isolated Experience in the Management of Severe Head Injury J Closed Head Injury J Neurosurg 1986; 64:89-98 Neurosurg 1981; 54:289-299 [8] Bullock R, Chesnut RM, Clifton G, et al Guidelines [25] for the Stablein DM, Miller JD, Choi SC, et al Statistical Methods for Management of Severe Head Injury 1995 Determining Prognosis in Severe Head Injury Neurosurgery [9] Clifton GL, Robertson CS, Choi SC Assessment of Nutritional 1980; 6:243-248 Requirements of Head Injured Patients [26] J Neurosurg 1986; 64:895-901 Bullock MR, Chesnut RM, Ghajar J, et al Appendix II: [10] Rapp RP, Young B, Twyman D, et al The Favorable Effect of Early Evaluation of relevant computed tomographic scan findings Parenteral Feeding on Survival in Neurosurgery 2006; 58 Head Injured Patients J Neurosurg 1983; 58:906[27] Toutant SM, Klauber MR, Marshall LF, et al Absent or 912 Compressed Basal Cisterns on First CT Scan: Ominous [11] Young B, Ott L, Twyman D, et al The Effect of Nutritional Support onPredictor of Outcome in Severe Head Injury J Neurosurg Outcome from Severe Head 1984; 61:691-694 Injury Neurosurgery 1987; 67:668-676 [28] Friedman G, Froom P, Sazbon L, et al Apolipoprotein E-e4 [12] Hadley MN, Grahm TW, Harrington T, et al Nutri Genotype Predicts a Poor Outcome in Survivors of Traumatic tional Support and Neurotrauma: A Critical Review of Early Nutrition in Injury Neurology 1999; 52:244248 Forty-Five Acute Head Injury Patients Neurosurgery 1986; 19:367-373[29] Nicoll JAR, Roberts GW, Graham DI Apolipoprotein E e4 [13] The Brain Trauma Foundation The American Association of Neurological Allele is Associated with Deposition of Amyloid B-Protein Surgeons The Joint Section Following Head Injury Nature Med 1995; 1:135-137 on Neurotraum a and Critical Care Nutrition J Neu[30] Clark JDA, Raggatt PR, Edward OM Hypothalamic rotrauma 2000; 17:539-547 Hypogonadism Following Major Head Injury Clin Endocrin [14] Harris JA, Benedict FG Biometric Studies of Basal Metabolism in Man 1988; 29:153-165 Washington, D.C 1919 Mayeux R, Ottman R, Tang MX, et al Genetic Susceptibility [15] Clifton GL, Robertson CS, Contant CF, et al Enteral Hyperalim antation in and Head Injury as Risk Factors for Alzheimer's Disease Head Injury J Neurosurg [31] 1985; 62:186-193 Among Community-Dwelling Elderly Persons and Their First [16] Ott L, Young B, Phillips R, et al Altered Gastric Emp Degree Relatives Ann Neurol 1993; 33:494-501 tying in the Head-Injured Patient: Relationship to Feeding Intolerance J Roberts GW, Gentleman SM, Lynch A, et al B Amyloid Neurosurg 1991; 74:738742 [32] Protein Deposition in the Brain After Severe Head Injury: [17] Grahm TW, Zadrozny DB, Harrington T Benefits of Early Jejunal Implications for the Pathogenesis of Alzheimer's Disease J Hyperalimantation in the Head- Injured Patient Neurosurgery 1989; Neurol Neurosurg Psychiatry 1994; 57:419-425 25:729-735 Mayeux R, Ottman R, Maestre G, et al Synergistic Effects of [18] Gadisseux P, Ward JD, Young HF, Becker DP Nutri- [33] tion and the Traumatic Head Injury and Apolipopro- tein-e4 in Patients with Neurosurgical Patient J Neurosurg Alzheimer's Disease Neurology 1995; : 555-557 1984; 60:219-232 Lee MS, Rinne JO, Ceballos-Bauman A, et al Dystonia After Head Trauma Neurology 1994; 44:13741378 Ebooksmedicine.net Head Injury: Long-Term Management, Complications, Outcome [34] Wade DT, Crawford S, Wenden FJ, et al Does Routine Follow Up After Head Injury Help? A Randomized Controlled Trial J Neurol Neurosurg Psychiatry 1997;62:478-484 [35] Alves WM, Jane JA, Youmans JR In: Post-Traumatic Syndrome Neurological Surgery 3rd ed Philadelphia: W B Saunders; 1990:2230-2242 [36] Mendez MF The Neuropsychiatric Aspects of Boxing Int'l J Psychiatry in Medicine 1995; 25:249262 [37] Parkinson D Evaluating Cerebral Concussion Surg Neurol 1996; 45:459-462 [38] Hof PR, Bouras C, Buee L, et al Differential Distribution of Neurofibrillary Tangles in the Cerebral Ebooksmedicine.net Ebooksmedicine.net Cortex of Dementia Pugilistica and Alzheimer's Disease Cases Acta Neuropathol 1992; 85:23-30 [39] Jordan BD, Kanik AB, Horwich MS, et al Apolipoprotein E e4 and Fatal Cerebral Amyloid Angiopathy Associated with Dementia Pugilistica Ann Neurol 1995; 38:698-699 [40] Jordan BD, Jahre C, Hauser WA, et al CT of 338 Active Professional Boxers Radiology 1992; 185:509-512 [41] Jordan BD, Jahre C, Hauser WA Serial Computed Tomography in Professional Boxers J Neuroimaging 1992; 25:249-262 927 61 ... Traumatic Intracranial Hematoma Neurotrauma New York: McGraw-Hill; 1996:689-701 [8] McKissock W, Taylor JC, Bloom WH, et al Extradural Hematoma: Observations on 125 Cases Lancet 1960; 2:167172... healthy tissue is encountered (further injury to deep midline structuresshould be avoided, here, stay within bullet tract) • contralateral fragments with no exit wound should only be removed if... injury Although most pediatric head injuries are mild and involve only evaluation or brief hospital stays, CNS injuries are the most common cause of pediatric traumatic death.1 The overall mortality