In the last 2 lectures we took about the skull, and we divide it into the cranial part and the

facial part. Last lecture we stopped at paranasal sinuses , we said that we have 5 paranasl sinuses ( maxillary,frontal,sphenoid,ethmoidal,mastoid) and we said that all of them open into the nasal cavity except the mastoid. Today we will start with new topic which is more important clinically and it called the skull fractures. When we speak about the skull fracture, we divide the fractures depend on the fractured bone, so we have fracture related to the cranial bone and fracture related to the facial bone. Now, the cranium of the skull (cranial bone) also is divided into: 1) the cranial vault (the roof &the wall). 2) The cranial base. So
Skull fractures

Cranial bone fracture

Facial bone fracture

Cranial vault fracture

Cranial base fracture

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So we will start with the fractures that usually happen to the cranial vault (calvaria). Before we start, you have to know that the skull itself is built up to resist up these kinds of fractures by 2 things: FIRST : convexity of the skull when you look to the skull ,you can see that it has rounded shape ,so when you have a blow on the skull ( la sam7 Allah ) the force (due to the convexity of the skull) will be distributed into waves all over the skull ,by these we will minimize the effects of the blow. SECOND: the buildup of the skull itself. If we look to the skull, we will see that it is made up of 2 tables of compact bone (outer & inner layers of compact bone) and there is layer of spongy bone between them. So, why it is made up of 2 layers of compact bone (diploid bone which is mean duple layer of bone)???? these usually happens because if you have a very large blow to the skull, these will lead to fracture to the outer layer , but you need another force (power) to fracture the inner one these is another way by which the skull will resist the fracture. SO REMEMBER THESE POINT **the skull will resist the fracture by 2 ways 1-the shape of the skull (convexity of the skull) 2-the tables formation (diploid bone) However, if the force is so strong, it may lead to fracture in both tables. The fractures that happen to the vault of the skull, it is usually classified into 4 or 5 kinds of fractures. 1) The most common one we refer to it as a linear fracture. As it is indicate, these fracture will go into a linear way (like line, LOOK TO THE PICTURE),
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2)

so the blow to the skull usually comes from a very fast object (like small stone), these will lead to a fracture which is radiating in both direction (in a linear way).

THESE THE MOST COMMON KIND OF FRACTURE THAT USUALLY HAPPENS TO THE CRANIAL VAULT OF THE SKULL (CALVIRA) NOTE: if the suture separate, these separation is considered linear fracture because the suture is linear also. 2) the second kind of fracture is caused by very heavy and large object , so when it blows down over the skull especially in a thin area ,it will destroy the skull ,and make it to be impressed inside ,and these also lead to further harmful to the under Neath soft tissue ( like meninges and brain) . This kind of fracture called depressed fracture, because the bones have been depressed inside to the cranial cavity. OK NOT THAT COMMON 3) Comminuted fracture what dose comminuted mean?? it is mean : kind of complicated OR there is a several segementes so ,in these case the object is large and it is very fast so it will lead to fracture of the skull into many small fragments -so , it is a strong blow & it will lead to fracture of the bone of the skull into several pieces AS A REVIEW

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Pterion **It is agreek word that is meaning a wing because it is close to the greater wing of sphenoid. **it is located about 3 cm above the midpoint of the zygomatic arch

until now we spoke about 3 kinds of fractures : 1-linear fracture 2-depressed fracture 3-comminuted fracture

4-NOW , the forth kind of fracture usually happens to the cranial wall in area called pterion area and we called it pterion fracture . What is the pterion??? It is the weakest point in the skull, which is distinguished by H shape suture. if you look to the skull laterally , you will find that there is apoint where 4 bones ( frontal,paraital,greater wing of sphenoid , temporal ) meet together and forming 5 different joints or sutures . so these area because there is so many sutures , if someone have a blow on the lateral aspect of the skull ,these will lead to separate the sutures ( THE MOST COMMON KIND OF SEPARATION WHERE YOU HAVE SO MANY SUTURES) . So it is a very dangerous region of the skull, why?? 1) The point of weakness (because there is so many sutures that is resembling the shape of the letter H.(LOOK TO THE PICTURE) 2)another thing is consider very important in the pterion fracture that is the largest meningeal artery which is providing blood supply to the meninges called middle meningeal artery . these middle meningeal artery enters the skull through foramen spinosum and then it will be distributed into anterior branch and posterior branch. The anterior branch is just directly passing to the internal surface of the pterion and it is even grooving the bone. NOW, these artery in the pterion and the pterion very common area to be fracture , so if there is a fracture in the pterion directly there will be injure in these artery.

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Hemorrhage : bleeding

Now, if this artery is injured, these will lead to severe bleeding (because it is from arterial source) these bleeding we refer to it as EPIDURAL HEMORRHAGE.

Epi: above ( outside) Dural: referring to the first layer of meninges, because this artery is located between the meninges and the skull bone.

So after injury there will be bleeding ,and then accumulation of blood the fractured site( bone) and the meninges. NOTE: epidural hemorrhage for all artery that are supplying the meninges ,the most common artery 80% to be injured is the anterior branch of middle meningeal artery because the most common fracture happened in the pterion . NOTE: the most common reason for the epidural hemorrhage is motor accidents (car accidents). NOW . What is happing there?? if there is a severe bleeding the blood will start to accumulate there ,pressuring the meninges , and in turn the meninges will pressuring the brain ,so if there is no drainage of these hemorrhage quickly the patient will get into coma within just half an hour and within hours (2 or 3) he will get into death. So, those are the fractures that affect the calveria: 1-linear.f 2-depressed .f 3-comminuted .f 4-specific one which is the pterion fractures. THE FRACTURE THAT ARE EFFECTED THE CRANIAL BASE Those fractures are further classified into 3 different parts depending on the location. As we know the cranial base from inside made of 3 fossa : 1-anertior cranial fossa. 2-middle cranial fossa which is butterfly shape. 3-poserior cranial fossa.
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NOTE: the cribriform NOW , if there is a fracture in the anterior cranial fossa **if the damage happened to the cribriform plate of ethmoid plate of the ethmoid is perforated to allow for the olfactory nerves to pass through it down into the nose. so the cribriform plate of ethmoid actually opened into the part fractured and also lead to tearing in the meninges ,it will cause kind of bleeding there , so the blood come from the brain all the way down into the nasal cavity then to the outside . These we call it EPISTAXIS. epistaxis mean: nasal bleeding . Causes More than 100 causes The last common cause eno there is a fracture to the anterior cranial fossa. So, the epistaxis doesnt only relate to the anterior cranial fossa fracture (any nasal bleeding called epistaxis) . But if you have severe blow on your skull, and then you find a nasal bleeding , you have to put in your consideration there is a possibility of fracture in the anterior cranial fossa. The more common thing to find a tearing of meninges , YOU KNOW that there is a fluid between the meninges and the brain , these fluid protecting the brain and act as shock absorber and it is called CERBROSPINAL FLUID (CSF) . y y y Note : Cerebrospinal fluid (CSF): -cerbro: from cerebrum -spinal: from the spinal cord nasal cavity ,so if these

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y y y

We can define it as: A clear colorless fluid, that comes from the filtration of the blood. -consider as A PLASMA FLUID.

So if there is a tearing of meninges ( sometime due to just a fracture to the cristagali ,so if it is fractured ,it will injure the meninges) once the meninges injured ,there will be a leaking of CSF into the cranial cavity, and then through the perforation of the ceribriforem plate of ethmoid to the nasal cavity . So if someone came to you with an accident , and he has a severe blow on his head ,and you see that there is a colorless fluid leaking from the nose that is mean there is a CSF leaking & that what we call it CEREBROSPINAL RHINORRHEA . What dose rhinorrhea mean ??? It is mean rhinenose (iam NOT sure about the spelling) Mean filtration of the CSF.

the third thing thing you going to find in the anterior cranial fossa is the EXOPHTHALMOS . exophthalmos : is meaning the bulging of the eyeball anteriorly outside the orbit . The exophthalmos indicates that there is a fracture in the orbital plate of the frontal bone, when there is a fracture the blood will leak into the orbit, so there will be a blood accumulation into the orbit and this accumulation will produce a pressure, and this pressure will push the eyeball outside. SO, AS A REVIEW Those are 3 different signs for anterior cranial fossa fractures: 1-epistaxis (nasal bleeding)

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2-cerbrospinal rhinorrhea(CSF running from the nose) 3-exophthalmos (bulging of the eyeball outside) FRACTURE IN THE MIDDLE CRANAIL FOSSA The most common fracture in the cranial base happened in the middle because it is the weakest part of the base of the skull due to there is so many foramina and canals there . NOW, if there is a fracture the CSF will not leak through the nose, it will leak through external auditory maitous. NOTE: petrous mean ROCKEY. These bulging inside the temporal bone actually happened because within it there is the internal ear and middle ear. So, nerve to the inner ear come from the brain then pass through the internal auditory meatous to the inner ear. So if there is a fracture in the middle cranial fossa and there is a leaking in CSF , the most common area that the CSF will pass through it is the internal auditory meatos then the inner ear then middle ear and finally the external ear opening to the outside . So, when you see patient have a leaking of CSF from his ear: that is mean these patient have a fracture in middle cranial fossa. Note : As you know, there is a connection between the external opening of the ear and the middle cranial fossa called INNER EAR OPENING (INTERNAL AUDITORY MEATOUS) which is located in the petrous of temporal bone.

*petrous part : huge elevation within the cranial base of the skull this part covered the Internal and Middle ear .

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The nerve of the inner ear comes from the brain and enters the internal Auditory Meatus and go to the inner ear

IF there is a fracture on middle cranial fossa , the most common site for leakage of CSF is ear , also there will be an injury to certain Cranial nerve ( 3rd,4th,6th) these nerve arise from middle cranial fossa and passing from there to superior orbital fissure to MOVE THE EYE BALL :) IF there is a fracture on middle cranial fossa there will be an injury to certain Cranial nerve ( 3rd,4th,6th) these nerve arise from middle cranial fossa and passing from there to superior orbital fissure to MOVE THE EYE BALL :)

Very Important nerve which is the largest Cranial nerve 5th Cranial nerve with its 3 branches Maxillary ,Mandibular < supply the upper and lower teeth > and Opthalmic branch . Maxillary nerve pass through foramen rotundum Mandibular nerve pass through foramen ovale

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Opthalmic nerve pass through superior orbital fissure , in this case of injury of the trigimnal nerve the patient will have paresthesia in his upper and lower jaw and lips . When you have a fracture in the middle cranial fossa this Cause leakage of CSF from ear, paresthesia in the upper and lower jaw and lips , cant move your eye ball .

Posterior cranial fossa fracture

Complicated fracture we cant notice it directly because the bleeding will accumulate On the back of the neck and covered by posterior muscles of the neck , the blood will accumulate between the bony part and those muscles it will take 24-48 hours to indicate this accumulation , this injury will go to the nerves that come from jugular foramina ( 9th, 10th, 11th) nerves .

Facial bone fracture

Always the facial bones are small and double so its gonna be a single bone fracture or complicated one complex ,, involving more than one bone.

Single fracture in facial bone commonly occur in the Nasal bone , or mandible

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*If you have any bony fracture that involve soft tissue damage * Complicated facial fracture :

Le fort use to drop the skulls from a roof of a high building then he go and analyze the pattern of the fractures so he find that the fractures happen in 3 levels of the weakness in the face so he called them : Level 1 = le fort 1 Level 2 = le fort 2 Level 3 = le fort 3 y Level 3 : the most dangerous one

Le fort 1 :
Called transmaxillary because it passing in a plane crossing the 2 maxillary bones , if you took a lateral view you will see that the fracture going all the way to reach the pterygoid process of the sphenoid bone.

Le fort 2 :
Passing through the sub- zygomatic *zygomatic bone is above this plane. plane involve several bones , other name is pyramidal because as you see its going in pyramidal shape in this case floating segment unstable segment will involve Nasal bone , Lacrimal bone , Maxillary bone and may posteriorly involve the pterygoid process.

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So ,, in le fort 1 all of the alveolar process and the teeth will drop Down. And in le fort 2 the pyramidal fragment that involve nasal , maxillary and lacrimal bones will drop down.

le fort 3 :
which refer to it as suprazygomatic but more correctly we will say about it CranioFacial because whole of the facial skeleton of the face will separate from cranial bone , this fracture involve Zygomatic, Maxillary , Nasal bones .

single fracture :
most common in the nasal bone ! Why ? prominence in the face ,, if you fall down the first thing you gonna hit is the nose small and tiny plate of bone
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The fracture of the nasal bone itself not severe condition but we get afraid from the complication that may be occur in this case. the complication happen if the fracture extend into the frontal process of the Maxilla which contributing on the middle wall of the orbit *Middle wall of orbit : frontal process of Maxilla lacrimal bone , ethmoid , and the body of sphenoid

The second complication is the injury within the frontal or ethmoidal air sinuses * because in the frontal bone we have frontal air sinuses behind the nasal bone down there is ethmoidal air sinuses.

Mandibular fracture :)
Although the mandible is the strongest bone of the facial skeleton but its the 2nd bone to be fractured , Why ?! * Movable bone ( only movable bone in the facial skeleton) 1. Condylar fracture : most common because of the narrowing in the mandible which mean less amount of bone , less density ,, easy to be fracture especially when you have a hit to your chin when your mouth is open ,, nothing to support the mandible only the area of the TM joint ,, so after the hit the whole mandible will go backward however the condyle fixed in TM joint , ones the mandible go backward the condylar neck will fracture 2. Body fracture : common fracture if its happen usually gonna be in the canine region because : * canine has the larger root so the larger socket less amount of bone- easy to fracture . * convexity . 3. Angel fracture : 1. Posterior downward
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2. Anterior downward . * What is the difference between them ?! downward backward : dislocation of the whole ramus superiorly . on the outer surface of the ramus there is a muscle called Masseter muscle that arise from the zygomatic arch and one from inside which called Medial pterygoid , if the mandible fractured at the angle region the ramus will go up by the action of these 2 muscles * superiorly dislocation of the ramus . Forward downward : no displacement the body of the mandible will prevent it >

4. Coronoid process fracture : the largest mastication muscle inserted on the coronoid process of the mandible so it will be superiorly dislocation by the action of the temporalis muscle . What you have to do due to the fracture ?! mandible is a ring bone passes in 2 sides if you have a fracture in one side you expect to find a fracture in another side may not be there but expect that and look for it :) so we have to see all sides of the mandible you need complete view it mean you have to use panorama x_ ray the best way to diagnose the fracture in the mandible because it will show whole parts of the mandible from side to side another , when you look to the picture you should pay attention to 2 important regions 1. Cortical margin 2. Mandibular canal you should follow them to discover any discontinuation which will indicate a kind of fracture .

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forgive us for any mistake ! best wishes ,, HAYA MOMANI ,, HEBA RADIADEH :)

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