skull fractures

Monday, November 12, 2012

Three quarterbacks in the NFL went down with concussions this weekend, a microscopic injury that cannot be seen on CT or MRI. Macro injuries happen as well, where damage to the skull may or may not impact brain function. Blake Geoffrion of the NHL Canadiens was playing for the minor league Hamilton Bulldogs during the NHL lockout and was caught with a body check sending him to the ice, hitting his head. While he was not knocked unconscious, he did leave the ice bleeding and shortly thereafter, ended up in hospital facing emergency surgery for a depressed skull fracture.

Normally, skull fractures are no big deal. IN fact, we don’t often look for them; plain skull x-rays are not routinely taken. We’re more interested in brain function than the state of the box that holds it. It’s like an egg. You can crack the shell but have a normal yolk inside, or you can shake it up, have a pristine shell and have a scrambled egg inside. It doesn’t mean that skull fractures don’t matter. Broken bones bleed and it’s important on physical exam to decide if the skull fracture is depressed on cave in.

A depressed fracture occurs when a direct blow to the skull drives a part of the bone below the level of the bone next to it, like pushing in on a ping pong ball. This can cause bruising and swelling to the underlying brain, plus the sharp bony edge can tear the dura mater, one of the linings or meninges of the brain.  Aside from brain function, the other important concern is whether the fracture is open or closed, whether the scalp is intact or has been lacerated. The outside world is not a clean place and the risk of major infection, like meningitis and encephalitis, increases dramatically when that world connects to the underlying brain or meninges.

A neurosurgeon is almost always involved in decision making when it comes to operating. Surgery is almost mandatory if there is an open fracture which is contaminated, a tear of the dura, if there is a subdural or epidural hematoma (a collection of blood between the skull and the brain) or if the bone is significantly depressed. The patient’s mental status, the physical exam and the CT scan help make the decision. Surgery cleans out the dirt, repairs tears and elevates and realigns the bony fragments. Occasionally, if there is minimal depression of the bone and all else is well, then watchful waiting is possible. Recovery does not depend upon the bone healing; the treatment goal is aimed at attaining normal brain function and preventing infection.

Skull fractures and bleeding in the brain are macro injuries, ones that can be found on physical exam, CT and MRI.  Often, watchful waiting allows the injury to heal but then there is the micro injury, the concussion that comes along for the ride. There is a big difference between macro and micro. With a skull fracture, one can see the severity of the injury. With a concussion, one can only imagine it.

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