Skull fractures

The brain is most damaged at the site of the skull injury (coup) and at the site of the opposite impact (contre coup). However, the existence of a fracture does not necessarily accompany a brain injury.

Classification of fractures

 * Based on breach of skin cover: closed; openly.
 * Based on dural breach: penetrating; non-penetrating.
 * According to the fracture line: linear (cracks, fissures); fragmentary (cominutive) with impression or elevation of the edges; impressive (impressive).

Cranial vault fractures
Comminuted fractures (comminuted)
 * Fissures (cracks)
 * Linear defects, if the brain is not damaged at the same time, have no major clinical significance and do not require special care. There is a risk, if the fracture crosses the course of the meningeal arteries, epidural bleeding.
 * In the case of an open fracture (intervention paranasal sinuses, skin wound above the fracture) preventive administration of ATB is necessary.
 * Diagnostics: native RTG, or CT.
 * As a result of a larger impact, the brain is usually also injured.
 * It can occur, for example, when the head is compressed (as in a vise) - the head "cracks like a nut", there may not be much damage to the brain, if only pressure and not speed was applied.
 * Impressive fractures (pivot)
 * The bone fragment is wedged intracranially.
 * Diagnostics: native X-ray or CT.
 * If the impression is in the place of venous drainage, there is a risk of significant subdural bleeding when the fragment is elevated.
 * If the brain tissue is pressed by the fragment, its elevation is necessary, because the pressure of the fragment may be a source of epilepsy in the future.

Cranial base fractures

 * They are serious, important structures are often injured - basal ganglia, brain stem.
 * They are caused by the action of a large force indirectly (hitting another part of the skull). Often they cannot be recognized on the basis of X-ray.

Fractures of the anterior cranial fossa

 * Usually a continuous fracture from the frontal landscape - the so-called 'frontobasal injury.
 * The fracture affects the area of ​​the lamina cribrosa, paranasal cavity, orbit.
 * A simultaneous defect in the dura, the mucous membrane of the paranasal sinuses or in the area of ​​the lamina cribrosa is common - open fracture (pathological communication with the external environment). This extent of injury can be indicated by nasal CSF (rhinorrhea), i.e. leakage of cerebrospinal fluid through the nose:
 * occurs intracranial hypotension,
 * if the patient is lying down, CSF flows into the nasopharynx, sometimes the patient describes a sweetness in the throat (sweet-salty taste),
 * diagnosis – glucose test, beta-trace protein, immunologically we demonstrate β2-transferrin,
 * can be even with a fracture of the pyramid → CSF to the middle ear and a tube to the nasopharynx.
 * Surgical therapy, antibiotic prophylaxis is indicated in the case of CSF.
 * To stop it, a bifrontal craniotomy is performed, larger openings are blocked with fascia, or muscleem (temporal fascia, fascia lata, allogeneic grafts, glue).
 * Other possible areas of injury: lobus frontalis, diencephalon, nervus opticus, chiasma opticum, nervus olfactorius, sinus cavernosus, a. carotid internal.
 * We observe a spectacle hematoma on the soft tissues of the eye. There may also be an injury to the eyelids, external communications may occur.
 * Complication:
 * Pneumocephalus,
 * intracranial infection (purulent meningitis, …).

Fractures of the middle cranial fossa

 * The fracture affects the petrous bone, sometimes also the temporal bone - a so-called temporobasal injury.
 * The middle ear, tympanum, auditus externus are also affected.
 * We can observe a retroauricular hematoma, bleeding from the ear or ear liquorea (otorrhea) if the dura and eardrum are damaged. If the eardrum is preserved, the fluid leaves through the Eustachian tube (paradoxical rhinorrhea).
 * The cerebrospinal fluid fistula heals soon, the cerebrospinal fluid usually stops on its own, but the resulting scar is worthless.

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