The fracture of a skull is a violation of integrity of bones of a skull. The severe direct injury becomes more often than it the reason: strong blow to the head, falling on the head from height, the trauma got as a result of a car accident, etc. However some types of changes can arise also at an indirect trauma – for example, when falling from big height on a basin or legs. The change is followed by local pain in the place of damage. Other symptoms depend on weight of a trauma, damage of brain structures and development of complications. Because of the accompanying damage of covers and substance of a brain fractures of a skull belong to the category of life-threatening damages at which obligatory hospitalization is necessary. Treatment is defined by a type of a change and weight of a craniocereberal trauma and can be both conservative, and quick.
Skull fracture – traumatic violation of integrity of a skull. As a rule, results from severe injuries: falling from the big height, car accidents, blows to the head by a firm massive subject etc. Usually is followed by injury of a brain and its covers therefore treats group of the states posing hazard to life. Tactics of treatment depends on a type of a fracture of skull and features of damage of brain structures and can be both conservative, and quick.
Fractures of a skull make about 10% of all changes and about 30% of total of severe craniocereberal injuries and are more often observed or at active people of young and middle age, or at socially unsuccessful citizens (alcoholics, addicts etc.). High frequency of similar damages at the first group of patients is explained by their activity (injuries production, trips cars, sports activities, including – extreme etc.). Injuries of representatives of the second group are more often connected with crime, or with accidents is able alcoholic or drug intoxication.
Allocate fractures of a brain and facial skull. Studying and treatment of fractures of facial skull represents the separate section of medicine which is under authority of maxillofacial surgeons therefore in this article we will not consider such damages. Neurosurgeons, and in the villages and towns which do not have own neurosurgical offices – traumatologists or surgeons are engaged in treatment of fractures of brain skull. All fractures of a brain skull are subdivided into two big groups: changes of the arch and basis. Basis changes in traumatology meet rather seldom and make about 4% of total of craniocereberal injuries. In character arch changes, in turn, share on:
- Linear fractures of a skull. Injury of a bone reminds the thin line. Shift of bone fragments is absent. Such changes in itself are least dangerous, however they can become the reason of injury of obolochechny arteries and formations of epiduralny hematomas.
- The pressed skull fractures. The bone is pressed into a cranium. Because of it the firm brain cover, vessels and brain substance can be damaged, bruises and a razmozzheniye of a brain, intracerebral and subduralny hematomas turn out to be consequence of what.
- Splintered fractures of a skull. At damage several splinters which can injure a brain and brain covers are formed, causing the same consequences that at the pressed changes.
Changes of the basis of a skull are subdivided into changes of a forward, average and back cranial pole. Perhaps also combination of changes of the arch and basis of a skull.
Allocate two mechanisms of a fracture of skull: direct and indirect. At direct the bone breaks directly in force place of application, at indirect action of blow is transferred to the injured bone from other departments of a skull or other bones of a skeleton. Skull arch changes usually result from a direct trauma. At the same time bones of a skull cave in inside, and the first damages an internal plate of a cranial bone. However, also indirect changes of the arch of a skull at which the injured bone is stuck out knaruzh are possible.
Skull basis changes develop owing to an indirect trauma, for example, as a result of falling from height on legs and a basin (in this case traumatic influence is transmitted through a backbone) or as a result of falling on the head more often (at the same time the blow is transferred from arch bones to skull basis bones).
At changes of the arch of a skull the wound or a hematoma of a hairy part of the head is found. In the field of a change there can be vdavleniye seen or revealed at palpation. It is necessary to consider that at linear changes such vdavleniye are absent. The general symptoms depend on weight of a trauma and a damage rate of brain structures. Any violations of consciousness, from its short-term loss at the time of a trauma to a coma are possible. At damage of a brain and cranial nerves there are sensitivity violations, paresis and paralyzes. The brain hypostasis which is followed by nausea, vomiting, the holding apart headaches, violation of consciousness and emergence of focal symptomatology can develop. At a sdavleniye of a trunk of a brain violations of breath and blood circulation, and also oppression of reaction of pupils are noted.
Usually regularity comes to light: the craniocereberal trauma is heavier, the consciousness violation is expressed stronger. However from this rule there is an exception – an intra cranial hematoma of which the enlightenment period which is replaced by consciousness loss is characteristic. Therefore you should not regard satisfactory condition of the patient as the testimony of absence or insignificant weight of a trauma.
One more factor which needs to be taken into account – patients with a skull fracture quite often are in alcohol intoxication which can complicate diagnostics. Therefore objective confirmations of an injury of the head (bruises, wounds, hematomas) and attestations of eyewitnesses in such cases have to become a reason for the direction of the patient on immediate inspection in specialized office.
At skull basis changes the symptomatology depends on the accompanying injury of a brain. Besides, the signs characteristic of damage of a certain cranial pole come to light. The symptom of "points" - hemorrhages in cellulose around eyes and the expiration of cerebrospinal fluid with blood impurity from a nose testifies to a change of a forward cranial pole. It is sometimes observed (a vypuchivaniye of eyes owing to hemorrhage in the cellulose located behind an eye). At injury of pneumatic cavities hypodermic emphysema can come to light.
The change of an average cranial pole is followed by the expiration of cerebrospinal fluid from acoustical passes and formation of bruise on a back wall of a throat. Heavy disorders of breath and blood circulation (the evidence of damage of a trunk of a brain) and bruises in the field of a mastoidal shoot are characteristic of a change of a back cranial pole (a bone ledge behind an ear). It is necessary to consider that the symptom of "points" and bruises to the area of a mastoidal shoot appear not at once, and in 12-24 hours after a trauma.
The fracture of a skull should be excluded at all patients with a craniocereberal trauma. The doctor interviews the patient, finding out circumstances of a trauma, estimates its general condition, conducts neurologic examination (estimates sensitivity and force of muscles, checks reflexes etc.). During survey it checks a condition of pupils (reaction to light, uniformity, width), existence or lack of a deviation of language from the average line and uniformity of a grin of teeth, and also measures pulse to reveal the bradycardia characteristic of a craniocereberal trauma. The survey roentgenogram of a skull in two projections, and if necessary – and in special laying is surely carried out. The computer tomography of a skull and a magnetic and resonant tomography (brain MRT) is appointed.
There is a number of the objective circumstances complicating diagnosis of fractures of skull including – serious condition of the patient because of which it is impossible to conduct a number of researches, features of a structure of a skull because of which in survey pictures injury of bones of the basis comes to light less than at 10% of victims etc. Therefore the diagnosis of a fracture of skull in some cases is exposed on the basis of a clinical picture and in the subsequent, after improvement of a condition of the patient, is confirmed by data of objective researches.
It is necessary to bring all patients with a craniocereberal trauma immediately in a hospital. At a stage of first aid of the patient stack in horizontal position. If the victim is in consciousness, it is put on a back. Patients in unconsciousness are stacked half-turned. For creation of such situation under a back on the one hand it is possible to enclose small pillows or outerwear. The head of the patient is turned aside that at vomiting he did not choke with emetic masses.
To the head create rest, using make-shifts: clothes, pillows or rollers. Stop bleeding, applying the pressing bandage a wound. To the place of a trauma put cold. Check passability of airways, if necessary eliminate a language zapadeniye, exempt airways from emetic masses etc. According to indications enter analeptik (, diethylamide of nicotinic acid) and warm glycosides.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Treatment of fractures of skull more often conservative, operations are performed according to strict indications. Conservative therapy is appointed to patients with the skull basis changes closed by skull arch changes, subarakhnoidalny hemorrhages, concussion and bruise of a brain. The bed rest which duration depends on weight of a trauma, and a head hypothermia is shown to all patients (bubbles with ice are used). Dehydrational therapy is carried out, antibiotics and anesthetics are appointed. At changes of the basis of a skull repeated lyumbalny punctures are carried out or the lyumbalny drainage is imposed.
Treatment tactics in each case is defined by weight and features of a craniocereberal trauma. So, at brain concussions to patients appoint vazotropny and nootropic medicines. At brain bruises the range of medical actions extends and includes not only means for improvement of a brain blood-groove and power supply of a brain, but also metabolic and anti-inflammatory therapy etc. In the recovery period apply nootropic medicines and medicines to improvement of brain microcirculation (cinnarizine, ).
Surgical treatment can be required at heavy fractures of a skull, especially – pressed. Under the general anesthesia trepanation during which the doctor creates an opening in a skull is carried out, deletes the taken root splinters, foreign matters and the destroyed fabrics from a brain. Formation of intra cranial hematomas in most cases is the indication for urgent operation in the course of which the surgeon deletes the accumulated blood, washes out a cavity, reveals and eliminates a bleeding source.
Injury of a facial or optic nerve, and in remote – the continuing expiration of cerebrospinal fluid from ear passes or the nasal courses can become the indication to surgical treatment at skull basis changes in the sharp period. The forecast at fractures of a skull depends on weight of a craniocereberal trauma. Perhaps both a complete recovery, and the serious consequences becoming the reason of disability of the patient.