Head Injuries Types of Skull Fracturesby STEVE HOLDER on JUNE 25, 2008

The skull is made of bone, and just like an arm or a leg bone it can be fractured. The type of skull fracture determines the injurys severity. These are the common types.

Linear Skull Fracture

A linear skull fracture is the simplest and most common type of skull fracture, comprising 2/3 of all cases. In a linear fracture, the skull bone is cracked, but the skull is not opened. The fracture itself is not dangerous and can potentially heal without special treatment. The danger, however, is that a blow severe enough to crack the skull may also cause a concussion or brain contusion.

Diastatic Skull Fracture

At birth, the skull consists of separate plates that are not fully joined together. As we mature, the bones fuse together and the joint between two plates is called a skull suture. A fracture causing the skull to separate at a suture is a diastatic skull fracture. Some medical professionals also use the term to describe an injury resulting in a significant separation of the bone at the site of the fracture.

Comminuted Skull Fracture

When a severe blow shatters the skull bone into small pieces at the injury site, its a comminuted skull fracture. This can be a very serious injury if small bits of bone are driven into the brain, tearing it and causing bleeding. It is less serious if the pieces remain in place and serious intracranial bleeding is avoided.

Depressed Skull Fracture

An extreme case of a comminuted skull fracture is the depressed skull fracture in which the skull fragments are pushed inward. Severe injury to the brain and dangerous intracranial bleeding is practically unavoidable.

Basilar Skull Fracture

A basilar skull fracture occurs at the base of the skull. Also called a basal skull fracture, its seriousness depends on its severity. A basilar skull fracture often tears the membrane surrounding the brain allowing the fluid to leak out, typically through the ears or nose. Leaking and bloody fluid may also collect in the area around the eyes creating a condition called raccoon eyes, or the fluid may create bruising behind the ears, referred to as Battles sign.

Presentation
Linear skull fracture
Most patients with linear skull fractures are asymptomatic and present without loss of consciousness. Swelling occurs at the site of impact, and the skin may or may not be breached.

Basilar skull fracture

Patients with fractures of the petrous temporal bone present with CSF otorrhea and bruising over the mastoids, ie, Battle sign. Presentation with anterior cranial fossa fractures is with CSF rhinorrhea and bruising around the eyes, ie, "raccoon eyes." Loss of consciousness and Glasgow Coma Score may vary depending on an associated intracranial pathologic condition. Longitudinal temporal bone fractures result in ossicular chain disruption and conductive deafness of greater than 30 dB that lasts longer than 6-7 weeks. Temporary deafness that resolves in less than 3 weeks is due to hemotympanum and mucosal edema in the middle ear fossa. Facial palsy, nystagmus, and facial numbness are secondary to involvement of the VII, VI, and V cranial nerves, respectively. Transverse temporal bone fractures involve the VIII cranial nerve and the labyrinth, resulting in nystagmus, ataxia, and permanent neural hearing loss. Occipital condylar fracture is a very rare and serious injury.[15] Most of the patients with occipital condylar fracture, especially with type III, are in a coma and have other associated cervical spinal injuries. These patients may also present with other lower cranial nerve injuries and hemiplegia or quadriplegia. Vernet syndrome or jugular foramen syndrome is involvement of the IX, X, and XI cranial nerves with the fracture. Patients present with difficulty in phonation and aspiration and ipsilateral motor paralysis of the vocal cord, soft palate (curtain sign), superior pharyngeal constrictor, sternocleidomastoid, and trapezius. Collet-Sicard syndrome is occipital condylar fracture with IX, X, XI, and XII cranial nerve involvement. [16, 17, 18]

Depressed skull fracture

Approximately 25% of patients with depressed skull fracture do not report loss of consciousness, and another 25% lose consciousness for less than an hour. The presentation may vary depending on other associated intracranial injuries, such as epidural hematoma, dural tears, and seizures.

Open And Closed Head Injuries An external force exerted over the head can be sufficient enough to fracture or displace the skull. Under such an instance, a patient is said to have contracted an open head injury. It should be remembered that the term open injury is specific to the skull and does not relate to brain damage. In closed type of brain injury, there is no damage to the skull. Based on type of force and amount of force, brain injury may be classified into different categories, as follows. Concussion: It is the most common and minor form of head injury. Ideally, concussion refers to a temporary loss of consciousness in response to head injury. Of late, the term has also been used to describe a minor injury of the head or brain, as a consequence of change in movement or sudden momentum. Contusion: Fracture of the skull can lead to a contusion. The skull is composed of bone tissue and protects the underlying brain. The inner surface of the skull is rough and hence friction caused due to movement of the brain within the skull can result in brain injury. Any bruising on the brain as a result of skull fracture is referred to as a contusion and represents a specific brain region of the brain that is swollen and mixed with blood from the damaged blood vessels. Coup - Contrecoup Injury: This is also a form of contusion in which the impact of a brain injury is significant enough to affect the other side of the brain as well. Bruises are therefore present on either side of the brain. If the impact of the damage is severe enough, it can lead to neuronal damage (neurons are structural and functional units of the brain), resulting in a breakdown of communication among neurons. Shaken Baby Syndrome: The condition can also occur as a response to back and forth movement of the brain, when a baby is shaken forcibly. This is commonly referred to as the shaken baby syndrome. The small size of the babies with respect to their relatively large head size in addition to lack of proper neck support and skull development can pose them at increased risk of this condition. Hematoma: Damage of a blood vessel in the brain and the consequent heavy bleeding around the brain, leads to hematoma. Three different types of hematoma exist, based on the location of the bleeding, namely epidural, subdural and intracerebral hematoma. Anoxia: Anoxia refers to brain damage as a result of complete reduction in oxygen supply to the brain tissue. However, the blood supply to the brain may be adequate. Hypoxia refers to a lack of proper oxygen supply to the brain. Starved of oxygen, cells in the brain die. This kind of brain damage is seen following drowning, heart attack or in people who suffer from heavy blood loss following extensive brain injury. Second Impact Syndrome: This kind of a brain injury is seen when a person with brain injury sustains a second injury. It can happen either days or weeks following the first injury.

What types of TBI are there?

Any injury to the head may cause traumatic brain injury (TBI). There are two major types of TBI: Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged. Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage: Primary brain damage, which is damage that is complete at the time of impact, may include:

skull fracture: breaking of the bony skull contusions/bruises: often occur right under the location of impact or at points where the force of the blow has driven the brain against the bony ridges inside the skull hematomas/blood clots: occur between the skull and the brain or inside the brain itself lacerations: tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain (the force of the blow causes the brain to rotate across the hard ridges of the skull, causing the tears) nerve damage (diffuse axonal injury): arises from a cutting, or shearing, force from the blow that damages nerve cells in the brain's connecting nerve fibers Secondary brain damage, which is damage that evolves over time after the trauma, may include:

brain swelling (edema) increased pressure inside of the skull (intracranial pressure) epilepsy intracranial infection fever hematoma low or high blood pressure low sodium anemia too much or too little carbon dioxide abnormal blood coagulation cardiac changes lung changes nutritional changes