Depressed fractures of the skull bones and their correction in children

Babies, as a rule, often fall in the first year of life, when they are learning to walk or due to the neglect of adults, falling out of bed is very common. If this occurs, it is important to calmly assess the situation and pay close attention to signs of injury.

Although it may look scary, falling out of bed usually does not cause serious harm. However, injuries can occur, so parents should know the signs that indicate their child needs medical evaluation after a fall.

Features of the structure of the children's skull

The prevalence of skull injuries in children is associated with the qualitative characteristics of the bone frame. In the first months after birth, bones do not have sufficient density. This quality allows the fetus to pass through the birth canal without damage. After birth, milk provides the body with various beneficial nutrients. They are embedded in the shell of the bones and give them hardness.

The skull has the same characteristics. It consists of several large bones. The components are the temporal, parietal, pubic and occipital bones. The parietal segment consists of two parts. The segments of the box are combined with each other with fibrous tissue.

The baby's head takes the correct shape a month after birth. The bones fall into place. The distance between them is closed by collagen fibers. As the fiber ages, it hardens. The skull acquires density and hardness.

During active movements, children acquire a variety of injuries. Due to the lack of reflexive defensive reactions, a large number of blows fall on the head. This is the reason for contacting a traumatologist.

Clinical manifestations

Obvious symptoms of a tumor of the base of the skull do not appear immediately. The clinical picture depends on the localization of the neoplasm and the degree of compression of the anatomical structures that are located next to the pathological area. The severity of symptoms is greatly influenced by the growth rate of the tumor.

Clinical symptoms are caused not only by extracranial manifestations, but also by general symptoms, which include the appearance of intoxication syndrome, which occurs in all malignant pathologies. In women, such changes are especially pronounced, which also include depressive changes, including those associated with the occurrence of facial deformities.

If the tumor spreads into the tissue of the ethmoidal labyrinth or frontal sinus, anosmia appears. Impaired nasal breathing, deformation of the bridge of the nose, and leakage of cerebrospinal fluid are also possible. Some patients experience decreased vision. When the tumor spreads to the mandibular joint, certain difficulties arise when trying to open the mouth wide. If the Eustachian tube is involved in the malignant process, the patient's visual functions are impaired. When the orbit is damaged, signs of unilateral exophthalmos and oculomotor disturbances appear.

Sometimes symptoms of a skull base tumor in adults affect the nasopharynx. This leads to a change in voice, the appearance of a characteristic nasal tone and problems with swallowing food. If the primary location of the tumor is the tissues of the nasal cavity or nasopharynx, there is a high risk of developing an initially malignant neoplasm. With a volumetric lesion of the orbit, neuro-ophthalmological changes occur, which cause the appearance of oculomotor disorders, lacrimation, and the development of exophthalmos.

Causes of head injury

Head injuries in children occur for various reasons. The following phenomena are considered negative factors:

• Vertical movement training;
• Accidental bruises on the plane;
• Violent labor activity;
• Additional negative factors.

In the first year of life, children learn to move vertically. The first steps are accompanied by frequent falls. If a small patient falls, he is not able to prevent possible injuries. This is due to the lack of a reflexive defensive reaction.

This fall occurs in the head region. A bruise is often accompanied by injuries to the skull.

Accidental bruises are also associated with a lack of defensive reactions. When you hit a hard surface or corner, pressure is applied to your head. The bones put pressure on the brain. The patient's skull is damaged. Due to the displacement of the bones, the main load is distributed to the cervical vertebrae. An examination reveals a fracture of the child's skull.

Experts also detect a skull fracture in infants. This head injury is associated with violent labor. To pass the birth canal, the bones of the box are shifted towards the crown. The baby's head extends. This allows you to avoid injury when passing through the pelvis.

What are the causes of craniosynostosis?

This disorder is quite often associated with diseases that can be inherited. These are so-called syndromic craniosynostoses. They become part of the clinical manifestations of genetic pathologies such as the syndrome:

• Apert;
• Crouzon;
• Pfeiffer;
• Setre-Chotzena;
• Carpenter;
• Nagera;
• Antley-Bixler et al.

With these diseases, patients often have a number of characteristic disorders. Depending on the syndrome, these may be various combinations of the following pathologies:

• bulging eyes;
• delayed development of the midface;
• fusion of fingers (syndactyly) on the hands and feet;
• growth retardation;
• mental retardation;
• an increase in size or, conversely, underdevelopment of the thumbs and toes;
• facial asymmetry;
• drooping frontal hairline;
• shortening and curvature of the bones of the hands;
• congenital pathologies of the cardiovascular system;
• fusion of other joints, etc.

Types of cranial injuries

Box fractures are divided into several types. There are two main types:

• Open type;
• Closed form.

An open bone fracture poses a danger to the patient's life. With such damage, part of the segment ruptures the soft tissue and is released into the external environment. In this case, small and large blood vessels feeding the epidermal tissue are ruptured. The risk of significant blood loss increases.

Large loss of blood fluid is accompanied by death in the absence of timely medical care.

Also difficult in open injuries is the combination of parts of the segment. In many cases, the patient requires urgent surgical intervention. Additional fastening elements are used for alignment. This increases the recovery time after surgery.

Often fractures are of the closed type. Such bone damage has no visible external symptoms. The doctor is guided by the patient’s complaints and a description of the situation preceding the injury.

Also, head damage has several forms. The forms are distinguished by the nature of bone splitting. Doctors distinguish fragmented, depressed and linear forms. In the comminuted form, several parts of the segment are detected on the x-ray image.

This form is dangerous for the proper functioning of the brain. The edges of the fragments have an uneven structure. The sharp edge damages the membrane of the brain and disrupts the integrity of the walls of small blood vessels. Treatment of comminuted fractures is also difficult. Additional medical devices are used to combine the resulting parts.

In case of blunt head injuries, a depressed fracture is diagnosed in a child. With a depressed form, the edges of the fracture enter the skull. They damage the lining of the brain and cause active internal bleeding.

Linear fractures of the skull bones are common in young patients. The linear form is characterized by the divergence of the medial edges of the parietal and frontal bones. This fracture is not dangerous to the life and health of the child.

Treatment methods in adults

The main treatment method is surgery. It is possible to carry out partial removal while preserving important anatomical structures and subsequent radiation therapy and chemotherapy. Specialists also carry out extensive resection of the pathological formation with further reconstruction of the skull base using artificial materials or autograft.

The specific tactics of surgical treatment are selected by the neurosurgeon, focusing on a specific clinical case. After surgery, the patient must be closely monitored. Pathology often produces relapses and distant metastases.

The neurosurgeon selects the appropriate approach to remove the tumor. Preference is given to techniques that provide a wide view during surgery. Most often, removal of the formation is carried out using anterior, posterior lateral or anterior lateral approaches.

Even before surgery, the neurosurgeon carefully examines the patient’s brain and determines the nature of the relationship between the malignant area and healthy brain tissue. Some formations are accompanied by a high risk of developing purulent complications. To prevent them, the neurosurgeon pays special attention to multilayer closure of skull base defects.

Operations of this type are considered complex and require highly qualified specialists. If possible, they are carried out at the Burdenko Research Institute, where there is all the necessary technical equipment for such surgical interventions. The main goal of the operation is to remove most of the malignant tumor with minimal damage to the functional structures of the brain. No conservative therapy can save a patient from the disease or improve his life prognosis. Only surgical treatment can be effective.

Post-traumatic activities

Diagnosis of a skull fracture in a child occurs only in a medical setting. The injury is detected using an x-ray machine. For complex fractures, magnetic resonance imaging is prescribed. To carry it out, the child is immobilized using anesthesia. This allows you to obtain accurate data. After diagnosis, the doctor prescribes the necessary treatment.

Before emergency medical services arrive, parents must follow a number of rules. Initially, it is necessary to immobilize the child. Any careless movement aggravates the patient's condition.

The patient should also be anesthetized. For closed fractures, the child is given an anesthetic drug appropriate for his age. A cooling bandage is applied to the injured area. It helps reduce swelling and has a distracting effect.

If there is a wound on the head, you need to treat it. The edges of the wound are treated with hydrogen peroxide or an aqueous solution of chlorhexidine. It is prohibited to treat deep wounds yourself. A sterile napkin is applied to its surface.

Skull injuries in children pose a health hazard. In young patients, in the absence of proper treatment, post-traumatic complications develop. Timely contact with specialists allows you to avoid problems.

Who treats craniosynostosis and how?

Obviously, such anatomical disorders of the structure and development of the skull cannot be corrected conservatively. Therefore, the main method of treating this pathology is surgery. Its essence lies in cutting the fused suture and carefully moving apart the cranial bones to free the brain structures. Anadolu surgeons recommend performing such an operation as early as possible, when there is the greatest chance of completely eliminating all the consequences of craniosynostosis. In our clinic, an interdisciplinary team is involved in the treatment of such patients, which includes neurosurgeons, orthodontists, radiologists, medical geneticists, ophthalmologists, otolaryngologists and other specialists.

To make an appointment to ask questions about the elimination of craniosynostosis in children at the Anadolu Clinic, you can call 8 800 550 6891 or check with the nearest regional office of the clinic in Russia.

The material was prepared in agreement with the doctor, medical professor Khalil Ibrahim Janter.

Classification

Depressed fractures occur when bone fragments are pressed into the cranial cavity. In this regard, these fractures are divided into:

• impression , when the anatomical connection of the fragments with the adjacent bones of the skull is preserved,
• and for depression – when the anatomical connection is lost.

Life forecast

The neurosurgeon tries to remove the tumor within healthy tissue. It is this tactic that gives the most favorable forecasts. It is extremely important to seek medical help at the first pathological changes and complaints.

Many patients mistake the initial symptoms of the pathology for symptoms of ordinary fatigue, lack of sleep, or a busy work schedule. It is better to play it safe and conduct several studies to make sure there are no pathological tumors. The life prognosis largely depends on the time of contacting a neurosurgeon.

Depressed skull fractures

Depressed skull fractures are a traumatic disruption of the integrity of the bony frame of the head, causing focal volumetric effects on the brain.
As a factor in traumatic compression of the brain, they occupy second place after intracranial hematomas. Not being a strictly independent clinical form of TBI, this type of damage has its own specific mechanisms of formation, morphological criteria and features of treatment tactics.

Classification

Skull fractures, in which bone fragments are displaced below the surface of the adjacent part of the cranial vault, causing compression of the brain, are classified as depressed. There are impression depression fractures of the skull, in which bone fragments remain connected to the adjacent intact areas of the cranial vault when the bone fragments are located at an angle to the surface of these areas, and depression depressed fractures of the skull, in which bone fragments lose connection with the intact bones of the cranial vault and are located below them surfaces.

In contrast to depressed ones, expression fractures are distinguished, characterized by the protrusion of fragmented bone fragments above the surface of the cranial vault.

Mechanisms of formation

The variety of options for depressed fractures is determined by a combination of certain external factors and the conditions of impact of damaging objects with the scalp. These include:

1) the ratio of the areas of the wounding object and the cranial vault;

2) the magnitude of the sent impulse of destruction force;

3) presence or absence of head acceleration;

4) the shape of the impact surface and the physical characteristics of the wounding object colliding with the skull;

5) intensity and duration of compression of the soft tissues of the head;

6) the degree of elasticity of the bones of the cranial vault and skin;

7) the presence or absence of shock-absorbing protective head coverings.

To form a depressed skull fracture, a direct contact collision of the surface of the head with a damaging object is required, the impact surface of which is many times smaller than the surface of the cranial vault.

The combination of a small impact surface of the striking object, its movement at high speed in conditions of reduced elasticity of the skull usually leads to the formation of impression fractures. In this case, for the appearance of a soft tissue wound, the degree of sharpness of the object, the high physical density of its structure, as well as reduced elasticity of the skin and the absence of protective head coverings (hat, helmet) are important. The degree of accretion of the dura mater to the bone determines whether the fracture will be penetrating or not. Therefore, in young people, even with deep penetration of bone fragments into the cranial cavity, the hard shell may remain intact. When a damaging object(s) with a narrow diameter is impacted on a stationary head, brain damage is usually limited to the epicenter of the impact. The inertial component of the impact does not allow accelerating the head sufficiently to form impact-resistant intracranial damage. If the head hits higher objects and structures when the body moves with acceleration (a fall from a height, a transport collision), then, along with the direct mechanism, an anti-shock mechanism also operates, since the force impulse is not completely exhausted in the area of ​​application of the impact by the counteraction of deformed and destroyed bone covers . In this case, a linear fracture is also added to the depressed one. Star-shaped, web-like configurations may form. All of them indicate a high intensity of impact.

A special type of impression occurs when there is a planar split of the outer and inner cranial plates with the formation of a depressed fracture of the latter. This is due to the unequal resistance of the outer and thinner inner plates to fracture upon impact with an object that has a blunt impact surface.

Fragmentary depression of the bone parallel to the surface of the cranial vault occurs when exposed to objects with a significant impact surface with great force. This leads to the pushing of a section of the bones of the vault of the corresponding area into the cranial cavity with the loss of anatomical connections with the surrounding bones. The energy of the injury may be exhausted at the site of skull destruction, and then the brain damage is localized at the epicenter of the impact.

When the head is hit with a powerful object, such as a log, in cases of incomplete fusion of the serrated sutures, an analogue of a depression fracture can form, when the bone scales along the suture are completely pressed below the inner surface of the adjacent bones.

The conditions for wound formation are similar to those for impression fractures. In the presence of standing edge-forming contours of the traumatic object, a “stamped” skin-aponeurotic fragment in the form of an island of tissue can form.

When the impact duration exceeds 200 ms, along with bone destruction, soft tissue compression also occurs, which can lead to focal necrosis with an increased risk of suppuration, especially when foreign bodies are introduced through crushed, blood-soaked integuments of the skull. When the main arteries supplying the scalp are crushed or post-traumatic thrombosis, skin necrosis can significantly exceed the size of the primary soft tissue lesions.

The conditions for the formation of depressed fractures are largely determined by the topography of the external influence. Fractures practically do not form in the projection of natural cranial buttresses: in the pterional zone and in the anterior sections of the origin of the pyramids of the temporal bones. Depressions are especially easy to form in places of thinned bone surfaces, such as the outer walls of the air sinuses (frontal sinus, pneumatized mastoid cells), the projection of the outer walls of the main sinuses of the dura mater, and the squama of the temporal bone. In the latter case, a large area of ​​thinned bone surface predetermines the conditions for the formation of impression-depression fractures. It is in such cases that obvious clinical and morphological dissociation is often observed: with rough impressions there are minimal clinical manifestations.

With depressed fractures in the projection of the venous sinus, its wall is damaged by bone fragments embedded in the cranial cavity with the formation of an irregularly shaped defect. Depressed skull base fractures are rare and are usually cranio-orbital or cranionasal injuries. The strength of the fusion of the dura mater with the bones of the anterior cranial fossa usually leads in such cases to the formation of penetrating fractures.

The scale of age-related features of the formation of depressed fractures is presented as follows: a decrease with age in the elasticity of soft tissues and bones of the calvarium with increased fusion with the underlying dura mater predetermines the more frequent formation of impression fractures in young patients, including isolated lesions of the internal bone plate, without damage dura mater. Also characteristic is the divergence of the serrated sutures with the depressed nature of the mutual position of the displaced bones. In young children, it is generally typical for a section of the skull to be pushed inward like a “watch glass” without the formation of a fracture. Elderly people are characterized by comminuted depressed fractures, often penetrating and causing the formation of wounds in the soft tissues of the head.

There are some specific features of the formation of depressed fractures during a fall from a height, during a motorcycle or other road injury, that is, when a moving head collides with a stationary object.

Clinic and diagnostics

The clinical picture in the presence of a depressed fracture consists of combinations of three groups of symptom complexes:

1) local changes in the scalp in the area of ​​impact application;

2) cerebral symptoms of prolapse, irritation and dislocation;

3) general somatic changes.

In the presence of a gaping wound, identifying a depressed skull fracture is not difficult. At the same time, with a closed head injury, even deep impressions may not be detected by palpation of the scalp due to swelling and imbibition of the soft tissues of the head by blood. Forced palpation of areas suspicious for depression is unacceptable due to the danger of displacement of fragments. At the same time, a ridge of edema that appears along the edges of the damaged muscle and aponeurosis can become a false-positive sign of a depressed skull fracture. Important primary orienting information is provided by the assessment of soft tissues at the site of impact: the presence of imprints of the contours of the impact surface of the traumatic object, the nature of blood flow from the wound, the presence of wound liquorrhea, subcutaneous crepitus. The last sign, indicating damage to the air sinuses, can quantitatively reach the extent of widespread epicranial pneumatocele.

There are no reliable clinical signs that would clearly indicate damage to the dural sinuses. Even the flow of venous blood through gaping cracks in the skull is not an absolute sign, as it is more often associated with damage to the parasinus veins. It is highly likely that a sinus injury can be suspected if fluctuations of a significant part of the scalp are detected on one or both sides (massive subgaleal hemorrhage), especially with small soft tissue injuries in the projection of the main dural collectors.

It is necessary to assess the nature of the introduction of foreign bodies and the survival of fragmented bone fragments.

Despite the importance of the local status in depressed fractures, the severity of the injury is determined not so much by the structure of the fracture as by the extent of damage and compression of the brain. It should be borne in mind that depressed fractures in many cases are not clinically manifested by either symptoms of prolapse or symptoms of irritation. Experience shows that in the acute period of injury, depressed fractures rarely manifest themselves as convulsive epileptic seizures, with the exception of cases of damage to the frontal lobes, especially their pole-basal sections. Neurological symptoms of prolapse often correspond to the localization of depressions of the skull with the formation of underlying foci of contusion and hemorrhage. However, in addition to direct compressive influences, indirect ones are also formed. The most obvious are shock damage to the brain and the formation of hemorrhages with the development of homolateral symptoms.

Another aspect is damage and compression of large arteries and veins. When the scales of the temporal bone are depressed and spread to the projection of the middle meningeal artery, an epidural hematoma can occur if the damaged vessel is not compressed between the fragments. With depressed fractures that involve the sinus drainage, but do not rupture its walls, visual loss is caused not only by direct compression, but also by a violation of the venous outflow. This type of lesion also causes the development of hydrocephalic-hypertensive symptoms due to disruption of liquor outflow through the cerebral aqueduct and the fourth ventricle.

Focal symptoms with compression of the sagittal and sigmoid sinuses are peculiar. Thus, with parasagittal depressions, along with contralateral paresis in the foot, pronounced paresis in the arm, mainly in the hand, often develops, which is caused by compression of large veins flowing into the superior sagittal sinus and draining blood from the middle and lower parts of the precentral gyrus. With retroauricular fractures with compression of the walls of the mastoid cells and overlap of the sigmoid sinus, headaches of a hypertensive nature occur, as well as Meniere-like syndrome with dizziness and wave-like hearing loss. The latter is associated with a violation of the outflow through the endolymphatic duct, which, as is known, opens with a wide mouth on the anterior wall of the sigmoid sinus.

The importance of recording local symptoms and their correlation with the topography of the impact should be emphasized. Thus, the appearance of nasal liquorrhea or signs of pneumocephalus when, for example, the parietal bone is depressed indicates the formation of a linear component of the fracture with a transition to the base of the skull. A similar mechanism explains other craniobasal symptoms, such as prosopoparesis, anakusia, etc.

Among the general somatic disorders, we note shock, hypovolemic hypotension, signs of fat embolism, which usually occurs in severe combined TBI with the formation of depressed fractures. Modern identification of the fact of fat embolism makes it possible to understand the reasons for the rapid neurological manifestation and refrain from emergency surgery.

The leading method for recognizing depressed fractures is x-ray diagnostics. Reliable information is provided by multi-projection craniography, which also allows one to recreate the mechanism of injury and clarify its nature, which was discussed above. There are classical descriptions of various options for impressions in the form of a cone, a cluster, vaulted patterns, etc. with a detailed description of the system of clearing and darkening. Craniographically it is easy to establish the presence of pneumocephalus and assess the dynamics of air resorption.

However, the role of craniography in fracture recognition is currently decreasing due to the widespread use of CT in bone mode. This method allows not only to detail the structure of fractures, but also to determine the state of the intracranial contents. The solution to the same problem is facilitated by the introduction of the MRI method into neurotraumatological practice.

Comprehensive information about the stereotopography, number and prevalence of depressed fractures of the calvarium and its base is provided by spiral CT, providing complete information for adequate spatial cranioreconstruction. The capabilities of this method will be discussed in more detail below.

Treatment

At the prehospital stage, ongoing venous bleeding from the wound is stopped by applying a tight bandage. In this case, it is necessary to avoid possible displacement of fragments of the depressed fracture. It is unacceptable to remove bone fragments or foreign bodies protruding from the wound, which can plug a defect in the wall of the venous sinus, large cerebral arteries and veins.

The presence of a depressed skull fracture is usually an indication for surgical treatment, since the embedded fragments cause irritation of the cerebral cortex, its compression, as well as possible occlusion from the outside of large venous and even arterial collectors. Along with fragments, foreign bodies and hair fragments often get into the wound, which increases the risk of developing purulent-septic complications. Contraindications to emergency intervention in the absence of signs of increasing compression of the brain occur in cases of shock, fat embolism, unrecovered blood loss, or the terminal condition of the victim. Conservative patient management is acceptable for closed fractures that occur subclinically under conditions of dynamic EEG control.

Despite the frequent occurrence of depressed fractures, there is still no unified concept of their surgery, especially in the acute period, and only a few reports are devoted to this issue in the world literature. If there is an uncontaminated wound and a small area of ​​bone damage, access through this wound is possible after refreshing its edges. In this case, bone mobilization is best carried out using high-speed systems, such as Stryker, using ball-shaped cutters of small diameter, with a border around the impression site. This ensures bone-preserving access. When using conventional megamills, the area of ​​bone tissue finally removed during access can be many times greater than the limits of the damaged bone.

In most other cases, bordering incisions of the scalp are necessary. Bone access is quickly and minimally traumatic using a high-speed craniotome (for example, Stryker). If free-lying bone fragments are found, fixed at the edges of the fracture only by the outer bone plate (due to chipping and displacement of the inner plate) in areas of the cranial vault outside the projection of the sinuses of the dura mater, mobilization of bone fragments is possible after biting the outer plate.

Detection of comminuted depressed fractures of the skull, especially involving the projection of the sinuses of the dura mater, requires extensive trepanation with the formation of a bone flap, the boundaries of which include all fragments. The same tactics should be followed in the presence of two depressed skull fractures located at a short distance from each other. Wide access allows, in the case of sinus bleeding or multiple topographically separated sources of bleeding, to quickly and reliably perform hemostasis.

In a number of observations, despite the deep penetration of bone fragments, the underlying dura mater of the brain appears to be intact (mainly in young people). In such cases, in the absence of preoperative CT data, it is necessary to dissect the dura mater with revision of the subdural space and the surface of the cerebral cortex (including using endocranioscopy through a small hole in the shell). You can refrain from subdural revision if there is a clear pulsation of the apparently unchanged dura mater and if the wound was heavily contaminated with foreign bodies.

If the dura mater of the brain is damaged, an extended subdural exploration is required with the removal of crushed areas of the brain, reliable hemostasis, and the introduction of chloramphenicol succinate (1 g of diluted powder) into the wound. After resection of the crushed areas of the dura mater of the brain, its plastic surgery is performed using a portion of the fascia (temporalis, fascia lata of the thigh). As is known, plastic surgery with lyophilized hard shell allotransplants is currently prohibited.

The optimal solution should be considered to be prosthetics of the hard shell using an appropriate Gortex membrane made of stretched polytetrafluoroethylene. This membrane, 0.3 mm thick, is close to the thickness of the natural dura mater. Its porosity of less than 1 micron ensures minimal tissue germination. Plasticity and softness allow you to repeat a given surface curvature. By covering the defect of the hard shell, the membrane acts as an inert intertissue barrier without adhering to the surrounding tissues. This prevents the formation of a rough scar. The waterproofness of the membrane ensures the prevention of wound liquorrhea.

With depressed fractures, the superior sagittal sinus is most often damaged as it is the most vulnerable (location at the apex of the cranial vault, large extent, thinning of the parasagittal sections of the parietal bones). The second most common injury is the transverse sinus. Damage to the confluence of sinuses in comminuted fractures of the occipital bone is often incompatible with life, although in addition to rupture of the sinus wall, it is only possible to block its lumen with fragments of a depressed fracture.

Adequate access, providing a sufficient angle of surgical action, is achieved with a wide trepanation, including the site of depression with damage to the sinus wall. At the same time, it is necessary and in modern conditions the effective use of reconstructive sinus plastic techniques with reliable hemostasis is possible. The cessation of bleeding at the moment of its detection is ensured by pressing the surgeon’s fingers on the area of ​​the hard shell in the projection of the sinus (determined by the blue staining of the shell) proximal and distal to the site of injury. Temporary hemostasis can then be achieved by inserting tampons epidurally along the edges of the burr hole in the projection of the sinus. More physiological is the introduction into the gaping lumens of the adductor and efferent sinus segments of a silicone tube with inflatable microballoons located at its ends. In this case, the cessation of bleeding from the sinus is achieved while maintaining blood flow through it. After these techniques, the main stage is performed - the final stop of bleeding. Suturing of the sinus wall is performed for slit-like defects with smooth edges. The peculiarity of the surgical technique here is the suturing of only the outer layer of the dura mater with matching of the inner layer in order to avoid sinus thrombosis. Reliable hemostasis and reinforcement of the outer wall of the sinus are achieved by applying and pressing a small TachoComb plate, which is a collagen sponge enriched with powerful hemostatic agents, to the site of damage (application is carried out with the yellowish surface of the plate facing the site of the defect). For a small defect in the wall of the parasinus lacuna, it is sufficient to introduce a piece of muscle into the defect with its fixation at the edges using bipolar coagulation, a fragment of Surgicel (a strip of oxygenated cellulose) or a TachoComb plate, which ensures rapid reliable hemostasis.

For perforated defects of the superior sagittal sinus, plastic surgery of its walls is performed depending on the topography, extent and nature of their damage. If one upper wall is damaged, plastic surgery is performed using a cut out flap of the dura mater near the sinus defect with interposition of a muscle fragment or TachoComb or a fragment of the temporal fascia with suturing with interrupted sutures. If a silicone tube is used, after applying the last ligature (without tightening), air is released from the balloons, followed by removing the tube and tying the ligature. If there is damage within the anterior third of the superior sagittal sinus, obturation with muscle strips or the above-mentioned biosynthetic materials is quite acceptable.

The most difficult thing is to stop bleeding from the sinus when the mouth of the superficial venous collectors is torn off, especially when chipped off sharp thin bone fragments invade the skull cavity, as if “cutting off” the vein at the mouth, as well as when two walls of the sinus are simultaneously damaged. In such cases, the optimal solution is access to the interhemispheric fissure with cutting out a section of the large falciform process and moving it to the upper wall of the sagittal sinus with suturing of the dura along the contralateral edge of the sinus with the obligatory introduction of a muscle strip or TachoComb plate between the layers of the shell. Such a reconstructive technique is necessary and possible when the posterior third of the sagittal sinus is injured, where access to the interhemispheric fissure is facilitated by the absence of significant veins and lacunae, and blocking the lumen of the sinus will inevitably lead to the death of the victim.

At the same time, if the wall of the sigmoid sinus is destroyed, obturation of its lumens with the same materials is fully justified, since the venous flow will pass through the lower anastomotic vein, which flows into the distal sections of the transverse sinus.

Ligation of the superior sagittal sinus is the worst option for hemostasis. In addition to the high risk of subsequent death (especially when ligating in the posterior segment of the superior sagittal sinus or dominant transverse sinus), the ligation process can damage the parasinus veins and dural lacunae with increased venous bleeding. In addition, even a correctly performed ligation may not provide hemostasis, since between the ligatures along the damaged wall of the sinus large veins can flow into it and lacunae can open. The above technologies for final hemostasis now make it possible to completely eliminate this ineffective and dangerous surgical technique and, despite the possible frightening massive bleeding, to quickly and reliably perform sinus reconstruction.

The final stage of reconstructive surgery for depressed fractures is restoration of the shape and surface of the skull. The optimal solution is primary plastic surgery of the defect using preserved large fragments of autologous bone and combining them by stitching with lavsan thread or gluing with medical adhesive compositions. Strengthening the bone mass is achieved using titanium microplates. The preservation of the external periosteum and the underlying dura mater ensures in such cases good survival of the fragments, preventing their migration into the cranial cavity. This complete, most physiological option is rational to use in the absence of gross brain damage, not only in cases of closed TBI, but also in the presence of a head wound without obvious contamination. When interposition of hair between large fragments with preserved periosteum, primary osteoplasty is permissible only after temporary separation of the fragments and complete removal of embedded hair and foreign bodies with thorough washing of bone fragments in an antiseptic solution, followed by the introduction of chloramphenicol succinate powder into the wound.

Depressed fractures of the outer wall of the frontal sinus are subject to resection with the removal of blood clots from its cavity and the release of the walls from the mucous membrane, tamponade with the muscle of the frontal sinus canal. In some cases, the operation is completed by drainage of the nasofrontal canal, and it is recommended to connect the bone fragments using titanium microplates. For small fractures with minor damage to the mucous membrane, it can be sutured and the bone defect closed with a free muscle flap.

In cases of crushed small bone fragments with lost periosteum, especially contaminated ones, with deep interposition of foreign bodies or hair, as well as with severe cerebral edema, primary cranioreconstruction is impossible or dangerous. Then it is especially important to use the “Gortex” dura mater prosthesis, which will ensure sealing of the wound and prevention of the cicatricial adhesive process while maintaining the structure of the soft tissue layers of the surgical wound. Delayed osteoplasty is performed using a number of inert materials, such as a graphite plate with a given surface curvature, hydroapatite cement, and a nickel-titanium mesh with spatial memory.

Cranioconstruction using computer modeling

To plan the reconstruction of multiple, complex-relief depressed fractures, a thorough assessment of their structural features, external and internal relief, the number of topically separated fractures, and their relationship with the surrounding intact bone formations is necessary. Neither craniography, nor CT in bone or tissue modes, nor MRI can fully reflect all these features. The introduction of spiral CT, which provides real three-dimensional spatial perception of a given object, significantly enriches the structural diagnosis of depressed fractures of the vault and base of the skull. This allows for refined preoperative modeling of embedded implants, ensuring their complete congruence with the surrounding bone tissue. This is of great importance for the implementation of reliable sealing of the cranial vault and the quality of cosmetic reconstruction of the craniofascial area. This solution is especially important when preparing an implant with a complex topography from a non-plastic material formed by casting a matrix (graphite, hydroapatite crystals, etc.). When using plastic masses (Palamed, etc.), accurate preoperative modeling of the contours of the implant is important for optimizing the cosmetic results of the operation and when introducing the matrix into deep wounds through the thickness of soft tissue.

The surgical technology of stereolithographic modeling based on spiral CT consists of the preoperative formation of a polymer profile of the external and internal contours of the patient’s skull using a laser device with precise adjustment of all details of the relief of the bone prosthesis on the formed phantom.

Complications and their prevention

Main complications:

1) soft-tissue scar (prevention - the use of ultra-sharp scalpels, which eliminate tissue crushing and provide cutting itself, made from a single crystal of zirconium dioxide, careful treatment of wounds and their sanitation);

2) suppurative processes, such as osteomyelitis (prevention - freeing fragments from foreign bodies, blood clots, sections of hair, removing small fragments devoid of periosteum, adequate drainage of the wound), encephalitis caused by deep penetration of foreign bodies, incompletely removed hematoma, which can lead to formation of delayed brain abscess;

3) brain scar that supports epileptic activity (prevention - careful treatment of the brain wound, layer-by-layer plastic surgery of integumentary defects using bioinert prosthetic membranes of the dura mater);

4) wound liquorrhea (prevention measures are the same).

Using a large amount of material, it was shown that the role of liquorrhea in the development of purulent-septic complications is tens of times more significant than the fact of the introduction of bone fragments into the cranial cavity. Among the rare complications, we note sinus thrombosis due to occlusion of the lumen of the dural sinus by depressed bone fragments. The microsurgical sinus reconstruction technologies noted above make it possible to avoid such complications.

Prognosis and outcomes

In many cases, even with extensive depressed fractures, the patient has no or mild cerebral symptoms, which is associated with the direct impact mechanism of TBI. However, developing focal symptoms of prolapse regress slowly and not always completely, especially with parasagittal depressions due to regional venous discirculation. Many patients experience good functional recovery. The prognosis worsens with the development of suppuration of the surgical wound after a penetrating TBI in the acute period, as well as with the formation of a brain scar that supports the epileptic syndrome.

Prognosis for damage to the walls of the dural sinuses. This life-threatening complication of depressed fractures often leads to the death of victims at the scene of the incident, during transportation to the hospital, or on the operating table - due to profuse bleeding; in the immediate postoperative period - due to cerebral edema and its dislocation due to gross venous discirculation (ligation, sinus thrombosis, coagulation of the mouths of the parasinus veins); in the long-term period - with symptoms of urosepsis (with damage to the cortical urinary center in the parasagittal parts of the parietal lobes). Impaired venous outflow can lead to persistent pyramidal disorders. When the patency of the damaged sinus is restored and there is no gross damage to the brain tissue, good functional results are often achieved.

Variants of the outcome as stated after a depressed fracture of the patient’s condition and the social activity associated with it can be distributed according to the depth of the predominantly affected layers of the head:

1) deformations of the skull - usually recorded in unoperated patients with a subclinical course of a depressed fracture;

2) defects of the skull with deformation of its contours - are determined when cranioplasty is not performed, and are often the basis for the development of trephine syndrome;

3) cicatricial adhesive lesions of the meninges - the result of reactive manifestations of resorption of interthecal blood accumulations, which can be the basis for the development and maintenance of hypertension syndrome;

4) intracranial foreign bodies - deeply embedded fragments of the external protection of the head or bone fragments in the brain remaining after surgery - the basis for the formation of convulsive readiness and epileptic syndrome, as well as delayed brain abscesses;

5) focal cerebral atrophy and adhesive-cystic cerebral process - a consequence of dysgemic disorders due to shock or shock damage to the brain parenchyma - can maintain a stable neurological deficit, epileptic syndrome or be asymptomatic.

Vladislav KARAKHAN, professor. Moscow Medical and Dental University named after. N.A. Semashko. Leonid LIKHTERMAN, professor, Institute of Neurosurgery named after. N.N.Burdenko RAMS.