Fracture of the base of the skull: survival and consequences of injury

A particularly severe injury in humans is a fracture of the base of the skull . Such an injury is characterized by damage to one of the bones that make up the base of the skull (occipital, sphenoid, temporal, ethmoid). The damage can be combined, in which several bones are damaged. Damage to the bones of the base of the skull accounts for 4% of all head injuries. A combination of damage to the base and vault of the skull is often found; according to statistics, this is from 50 to 60%.

Causes of damage

In order to damage the base of the skull, the injury must be high-energy. A similar factor is:

• traffic accident;
• falling from height;
• hit to the head or face area with a hard object;
• hitting your head on a rock while diving.

After injury, a fracture of the base of the skull bones is accompanied by damage to other bones and organs. Despite the strength of the bones, there are weak spots on the skull that can be damaged. The anatomy of this part of the head will help to better understand the symptoms.

Structure of the base of the skull

It simply doesn’t make sense to analyze the structure of the base of the skull in detail; this detail is best left to doctors. The boundary between the base and the arch is a line passing through specific anatomical formations.

A photograph provides a visual representation of the structure of the base of the skull and its boundaries. Doctors classify such injuries based on location and cranial fossa. There are anterior, middle and posterior cranial fossae with many holes. Vessels and nerves penetrate the cranial cavity through them; the relief almost completely replicates the brain.

Damage classification

Damage may be open or closed. In the first case, there is a wound above the site of injury, at the bottom of which there are bone fragments. Open fractures are much more complicated due to the possible risk of complications, primarily infectious.

Fractures of the base of the skull are often linear; less often they can be comminuted. Basically, the classification depends on the location of the damage in the cranial fossa. There are also injuries with or without displacement, complicated by damage to blood vessels, nerves or the brain; in such a situation, the consequences of a fracture of the base of the skull are much more serious.

Changes in dynamics

In Fig. 20a fresh fracture of the squama of the occipital bone, arrow in Fig. 20b the same fracture ½ year later. The subgaleal hematoma above the fracture has regressed, and the diploe along the edges of the fracture is sclerotic, but there is no bone consolidation. In Fig. 20c there is bone hyperostosis on the inner surface of the diploe under the fracture site (yellow arrow) - this is a bone fusion that forms over the years, more often occurs in children, less often in adults. If glial changes develop in the brain under the fracture site, leading to the expansion of cerebrospinal fluid cysts, then the bones can move apart and the fracture is called “growing” (the same changes occur during the formation of a cerebrospinal fluid cavity - a cyst and an increase in intracranial pressure).

Fig. 20 Fibrous fusion with absence of callus and bone consolidation on CT.

Survival after damage

When a person survives such serious damage, it can be considered true happiness. It all depends on how first medical aid is provided, how quickly the victim is taken to a medical facility and surgical intervention is performed. Damage to the bone causes severe bleeding, leading to death or prolonged coma. In such a situation, the survival rate is extremely low; most victims die within the first minutes or days. When the body has coped and managed to survive, the lifestyle changes significantly after the injury. Often a disability group is assigned due to impairment of vital functions and intelligence.

If the fracture is not displaced, in the form of single cracks and does not require surgical intervention, the prognosis is relatively favorable. A fracture of the base of the skull leads to death in 24-52%, depending on the severity, complexity of the injury and complications.

Possible consequences

The prognosis is not always positive; it all depends on the degree and type of injury, the presence of fragments and the area of ​​damage, as well as the timely provision of pre-medical and qualified medical care. If the cracks are single, there are no fragments or displacements, and the brain has not been compressed, then the person can expect a full recovery.

When inflammation occurs, the victim faces: encephalopathy, constant surges in blood pressure, migraine, suffocation. More serious pathologies: complete paralysis of all muscles, distortion of the symmetry of the face, spine, coma, death.

The risk of serious complications is significantly reduced with timely, correct diagnosis and immediate treatment. Try to avoid conflict situations, be careful while driving and do not abuse alcoholic beverages. Take care of your health and always listen to the recommendations of doctors.

Symptoms of a skull fracture

Immediately after receiving an injury, attention is drawn to the typical manifestation of a fracture of the base of the skull. It all depends on the severity of the injury, the location of the fracture and the degree of damage to brain structures. The degree of loss of consciousness and its duration can range from short-term loss of consciousness immediately after injury to deep coma.

The degree of impairment of consciousness depends on the severity of the brain damage. The victim is bothered by a headache; with a hematoma in the cranial cavity after receiving an injury, a period of clarity begins, after which the person loses consciousness. This should not be a criterion for the ease of injury.

General symptoms of damage are identified.

1. Expanding headache due to cerebral edema.
2. Nausea, vomiting, which can go into the lungs, resulting in aspiration pneumonia, for which antibiotics may not help.
3. Bruises appear around the eyes, this is called a symptom of glasses.
4. The pupils have different diameters and do not react to light.
5. When the posterior fossa is damaged, the brain stem is damaged or compressed, resulting in impaired breathing and circulation.
6. CSF or cerebrospinal fluid mixed with blood leaks from the nose or ears.
7. The activity of the heart is disrupted in the form of arrhythmia, tachycardia, bradycardia, increased or decreased blood pressure.
8. The victim is agitated or immobile.
9. Consciousness is confused.
10. Involuntary urination.

Damage to the pyramid of the temporal bone

Damage to the temporal bone pyramid may have a longitudinal, transverse or diagonal fracture line. With longitudinal damage, the activity of the middle and inner ear is disrupted and the facial nerve is damaged.

Conservative therapy for injury

Conservative treatment is carried out for uncomplicated linear fractures when the intervention of a neurosurgeon is not required:

• Conservative tactics involve strict adherence to bed rest. In this case, the patient’s head should be slightly elevated so as not to create conditions for cerebral edema and stagnation of cerebrospinal fluid,
• To reduce cerebral edema, dehydration therapy is carried out , which includes the mandatory use of diuretics. For this purpose, Diacarb, Mannitol, etc. can be used.
• To prevent purulent complications, broad-spectrum antibacterial drugs are used, which can be used in the form of intravenous, intramuscular infections, as well as endolumbarally, that is, by injection into the spinal canal. The following drugs are used: Monomycin, Levomycetin, Polymyxin, Kanamycin, etc.,
• In some cases, cerebrospinal fluid is cultured on a nutrient medium to determine the sensitivity of microorganisms to antibiotics. In the prevention of infectious complications, much attention is paid to the sanitation of the oral cavity, nose and ear.

Subtleties of first aid

Immobilization according to Bashmakov

Immobilization with Elansky splint

In the victim, immediately after its discovery, it is necessary to suspect a fracture of the base of the skull until this assumption is removed by the doctor after an appropriate examination. It is worth remembering: if there is bleeding, then with unnecessary movements it can intensify, reducing the percentage of survival after injury. If there are objective signs of a fracture of the base of the skull, the person urgently needs to be taken to a medical facility.

At the scene of the incident, the head must be immobilized; this can be done using Krammer splints using the Bashmakov method. An Elansky splint, which is often made of plywood, will also help immobilize the head. If such tires are not available, you can use any available means, for example, a piece of plywood placed under the head and upper body. Additionally, a “donut” made of fabric or towel is placed under the head.

Cold is applied to the head, which will help reduce the extent of brain damage. When there is a wound, a sterile bandage is applied to it if possible. The victim must be transported strictly in a horizontal position. The head is turned gently to one side, which allows for the prevention of aspiration of vomit.

Diagnosis of damage to the base of the skull

Even one symptom characteristic of a fracture of the base of the skull can lead an experienced doctor to make the correct diagnosis. In most cases, a special examination is required. The most primitive method is an x-ray of the skull bones, always in two or even three projections.

A CT scan of the head will provide the most information. The sections clearly show all the damage and structures that are not visible on the x-ray. MRI will give an idea of ​​the condition of soft tissues, including the brain. All hemorrhages will be visible on the image, and their volume can also be calculated.

Based on CT and MRI images, doctors decide on the tactics for further treatment of the fracture and the need for surgical intervention.

Bone fracture

21315 01 December

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-treatment.
In case of pain or other exacerbation of the disease, diagnostic tests should be prescribed only by the attending physician. To make a diagnosis and properly prescribe treatment, you should contact your doctor. Bone fracture: causes, symptoms, diagnosis and treatment methods.

Definition

A fracture is a complete or partial disruption of the anatomical integrity of a bone, accompanied by damage to the soft tissue surrounding the bone and disruption of the function of the damaged segment. Fractures usually occur as a result of injury or overuse. Fractures can be closed, when the skin and surrounding tissues are not damaged, and open, when the surrounding tissues and skin are ruptured, and the broken bone comes into contact with the environment through the lumen of the wound.

Causes of fractures

The severity and characteristics of the fracture depend on the type of bone, the condition of the bone tissue, the vector and area of ​​application of the traumatic force:

• Traumatic (mechanical)
  fractures usually result from the sudden application of significant mechanical force to a healthy bone, such as from a fall, impact, motor vehicle accidents, or during outdoor activities and sports (sports injuries).
• Stress (stress)
  fractures are small partial fractures of bones caused by repeated moderate stress rather than a specific injury. They can occur, for example, in long-distance runners or in soldiers walking with a heavy weight on their back.

• Pathological (spontaneous)
  fractures occur when a small or minimal impact results in a fracture of a bone affected by some disease. This happens with osteoporosis, osteomyelitis, cancer, infections, bone tumors (osteomas, osteoblastomas, etc.), systemic connective tissue diseases, genetic diseases and developmental defects. Thus, to get a fracture, it is enough to step off a step unsuccessfully or make a sudden movement.
• that occur during childbirth,
  such as a depressed skull fracture, are the result of the baby's head pushing against a bony protrusion in the womb or from the use of forceps during delivery.

When bones are broken, other tissues can be seriously damaged, including skin, nerves, blood vessels, muscles and internal organs. Such injuries complicate the treatment of the fracture and cause temporary or chronic problems.

There are several stages in the bone healing process:

Inflammatory stage

- healing begins immediately after the fracture. Immune cells release substances that attract even more immune cells and increase blood flow to the site of injury. As a result, the area around the fracture becomes inflamed and develops redness, swelling and tenderness.

Recovery phase

begins a few days after the injury and lasts from several weeks to several months. As the bone heals, a callus forms. At first, the callus is soft and elastic and can be easily damaged and become dislodged. In addition, it cannot be seen on an x-ray.

At the remodeling stage

the bone is restored and returns to its previous state. Calcium is deposited in the callus, making it harder and stronger; it can already be seen on an x-ray, and the normal shape and structure of the bone is restored.

Healing occurs better when the broken bone pieces touch and align. Even fractured bones, with proper treatment, can often heal and maintain normal function. The speed of bone healing depends on the age of the victim and the presence of concomitant diseases (diabetes mellitus and peripheral arterial disease slow down the recovery of bone tissue). Children's bones heal much faster than adults'.

Classification of fractures

Depending on the nature of bone damage, fractures can be complete or incomplete. Incomplete fractures include cracks, subperiosteal greenstick fractures in children, perforated, marginal, fractures of the base of the skull, fractures of the internal plate of the calvarium.

In the direction of the fracture line:

• transverse - the fracture line is located perpendicular to the axis of the bone;
• oblique – the fracture line passes at an acute angle to the axis of the tubular bone;
• longitudinal - the fracture line runs along the axis of the bone;
• splintered (fragmented, finely splintered, coarsely splintered) – the fracture line is broken;
• helical, or spiral - twisting of bone fragments along its axis while rotating the ends of the bone in opposite directions;
• compression – compression of one or several vertebrae at once, leading to rupture of bone tissue;
• avulsions - a fragment of bone is torn from the main part of the bone by a ligament or tendon.

Depending on the presence of displacement of bone fragments, fractures can be without displacement or with displacement.
There are offsets:

• in width (diameter) – the distal part of the bone shifts;
• by lenght:
• a) with divergence of fragments;
• b) with shortening (impacted fracture);
• c) combined displacement - along the width and then along the length;

Based on location,
fractures are divided into diaphyseal (tubular bone fractures), metaphyseal (periarticular) and epiphyseal (intra-articular). Epiphyseal fractures are the most severe.

According to the complexity of fractures there are:

• simple - without bone displacement and tissue damage;
• complex (complicated) - with displacement of bones, with fragments, with damage to blood vessels, nerves and organs;
• multiple – several fractures in one anatomical area (for example, a fracture of the hand);
• combined – damage in two or more anatomical areas, regardless of their number and functional orientation;
• combined - occur under the influence of several damaging factors.

Symptoms of fractures
When bones are fractured, the patient experiences reactions from the whole body - traumatic illness, fainting, collapse, shock. The most obvious symptom of a fracture is pain in the area of ​​the fracture. If the muscles around the injured area try to hold the broken bone in place, the muscles may spasm, causing additional pain. Other symptoms include:

• swelling that develops within a few hours after the fracture;
• deformation of the bone at the fracture site that appears twisted or displaced;
• With subcutaneous hemorrhage, bruising or discoloration of the skin occurs. Hematoma with pulsation indicates continued bleeding;
• impossibility of normal movement in the injured area. However, the ability to move the injured part of the body does not mean the absence of a fracture;
• loss of sensation (numbness, tingling or other abnormal sensations);
• crunching of bone fragments under the skin;
• increasing pain with axial tapping (along the bone);
• with an open fracture, bone fragments are visible visually, and there is bleeding from the wound.

The general condition of victims with isolated fractures is usually satisfactory.
With multiple, combined, open fractures, the serious condition is often caused by traumatic shock. Diagnosis of fractures

Diagnosis begins with a history and physical examination to rule out damage to the blood vessels (checking pulse, temperature, skin color) and nerves (checking sensitivity) near the injured part of the body, as well as determine the mobility of the injured area, check for damage to joints, ligaments, tendons and muscles.

Imaging tests used to diagnose fractures include:

• ;
• ;
• .

Other tests may be done to check for fracture-related injuries:

• angiography (X-rays or CT images taken after injection of a contrast agent visible on X-rays into the arteries) to rule out damage to blood vessels;
• studies of nerve impulse conduction.

Which doctors to contact
If you suspect a fracture, the victim, independently or with outside help, should contact a traumatologist or the emergency department. The victim is always taken to the emergency room in the event of a car accident, multiple injuries, loss of sensation and/or lack of normal movement in the injured area.

Treatment of fractures

First aid for open fractures is to stop external bleeding and apply an aseptic dressing to the wound. It is necessary to ensure immobility of the site of bone fracture using splints or improvised means, apply ice to the injury site, apply a pressure bandage, and you can give the victim a painkiller.

Stages of treatment:

1st stage. Reposition - comparison of bones.

• Closed manual one-stage reduction is used for a closed displaced fracture.
  The intervention is performed without surgery. The surgeon performs reduction with his hands. Plaster is applied to fix and hold the bone fragments in the desired position.
• Open manual one-step reduction is required for open and comminuted fractures. The operation is performed by cutting through soft tissue to gain access to the damaged bone. If there are hematomas, they are opened, the injured vessels are sutured, the bones are compared and they are fixed.
• Closed hardware simultaneous reduction - wires are inserted above and below the fracture site under local anesthesia, the wires are fixed with a device. In the X-ray room, fragments are compared and the limb is cast together with knitting needles.
• Gradual reduction by skeletal traction. Under local anesthesia, one wire is passed through the bone and secured in a specially designed bracket. Then, a reduction weight is installed through a system of blocks to traction the limb.

2nd stage. Immobilization – immobilization of the fracture site.

• A plaster cast or orthosis that covers two joints adjacent to the fracture.
• Osteosynthesis is the fixation of bone fragments using special fixing structures. Pins, nails, screws, screws, knitting needles, etc., made from special materials, are usually used as fasteners.
• Hardware method – external fixation of bone fragments using metal structures (Ilizarov, Obukhov, etc.) without direct impact on the bone.

3rd stage.
Consolidation – activation of bone fusion. Bone consists of proteins, calcium, phosphorus, and organic substances, so for its speedy restoration, proteins, fatty acids, calcium supplements, and vitamin D are required (for better absorption of calcium). Medicines used include circulatory stimulants, antiplatelet agents, anticoagulants, immunostimulants, and biological activators.

If the bone has not healed properly, then an artificial fracture is performed, and then an operation (osteotomy), during which the bones are again compared and immobilized.

4th stage. Rehabilitation.

The task of this stage is to restore tissue trophism in the fracture area, prevent contractures, and restore range of motion in the joints. Recovery may include massage, therapeutic exercises, etc.

Complications

Many fractures cause severe internal bleeding around the injured area or external bleeding from an open wound, which can cause a life-threatening drop in blood pressure.

Pulmonary embolism is the most severe, fatal complication of serious fractures of the pelvis and hip joint.

Pulmonary fat embolism is rare but does occur when long bones (such as the femur) are fractured. Compartment syndrome develops in rare cases when there is severe swelling of the damaged muscles due to a broken limb or a Lisfranc fracture (a type of foot fracture). Swelling in the injured limb reduces or blocks blood flow. As a result, part of the bone fragment after a fracture may become necrotic.

A tendency to osteonecrosis is also often observed in closed displaced fractures.

With any fracture there is a risk of infection, but it is especially great with open fractures. Acute infection can lead to the development of osteomyelitis and sepsis.

Long-term complications of fractures include degeneration of articular cartilage and osteoarthritis if the fracture involves the surface of a nearby joint.

Improper fusion of bones leads to residual deformation and the formation of a false joint.

If a fracture in children affects the growth plate of the bone, one limb becomes shorter than the other.
Prevention of fractures
It is necessary to adhere to well-known recommendations aimed at preventing injuries and maintaining normal bone density.

Sources:

1. Traumatology and orthopedics. Kornilov N.V. // St. Petersburg: Hippocrates – 2001. – 408 p.
2. Traumatology and orthopedics: A guide for doctors / ed. N.V. Kornilova: in 4 volumes // St. Petersburg: Hippocrates, 2004. – T. 1: General issues of traumatology and orthopedics. – 768 p.
3. Injury. In 3 vols. T 2. / David V. Feliciano, Kenneth L. Mattox, Ernest E. Moore / trans. from English; under. ed. L.A. Yakimova, N.L. Matveeva // – M.: Panfilov Publishing House; BINOMIAL. Knowledge Laboratory. – 2013. – p. 736.

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-treatment. In case of pain or other exacerbation of the disease, diagnostic tests should be prescribed only by the attending physician. To make a diagnosis and properly prescribe treatment, you should contact your doctor.

Therapeutic measures

Very often, fractures of the bones of the base of the skull require surgical intervention. However, it is possible to treat such damage conservatively, which means a favorable outcome and the absence of severe brain damage. The decision is made individually and depends on the results of the study. Let's try to understand the features of one and the other direction in the treatment of fractures of the base of the skull.

If a person loses consciousness, it is indicated to be hospitalized in the intensive care unit. Additionally, intubation and inhalation with humidified oxygen are indicated. The doctor prescribes medications designed to maintain brain function and prevent the destruction of its structures. There must be constant monitoring of blood pressure, heart rate, and fluid injected and excreted.

Treatment

Once the diagnosis has been established and the existing injuries have been assessed, emergency treatment for a basal skull fracture begins. It consists of several stages and can be conservative or surgical.

Basics

The first stage is treatment aimed at eliminating life-threatening symptoms and restoring bone integrity. Conservative therapy can be carried out only in the case of simple linear fractures without displacement or depression of fragments.

The patient requires complete rest, strict bed rest, and a therapeutic diet. Drug treatment includes the use of the following drugs:

• infusion therapy - solutions of glucose, sodium chloride, polyglucans;
• diuretics - to prevent the development of cerebral edema;
• means for normalizing cardiac activity;
• if a brain contusion and a fracture of the base of the skull occur simultaneously, the introduction of nootropics, means for restoring nerve cells, is required.

The duration of the patient's stay on bed rest depends on the severity of the injury, but is always at least three weeks.

Surgical treatment is required in cases where there are complicated fractures. The fragments are compared and osteosynthesis is performed using screws and metal plates. After this, drug therapy is prescribed to eliminate brain damage. The treatment time for patients with complicated fractures increases significantly.

Video in this article:

Nursing care for a fracture of the base of the skull is of great importance in the management of such patients. Patients must be placed on strict bed rest, meaning they are not allowed to even sit up in bed. Therefore, there should be a nurse near the patient - albeit not constantly, but with the possibility of visiting him regularly.

Recovery period

After the main symptoms have been eliminated and the integrity of the bones has been restored, rehabilitation after a fracture of the base of the skull begins. It is necessary for the social adaptation of the victim, restoration of motor activity and other impaired functions.

Rehabilitation includes therapeutic exercises, massage, and work with a psychologist. If necessary, treatment is provided by a neurologist.

Conservative approach

The main indication is mild to moderate trauma; liquorrhea and signs of nosebleeds should be eliminated without surgery. The patient is given strict bed rest; the head should be positioned slightly higher than the body, in this way the amount of cerebrospinal fluid secreted can be reduced.

Rehabilitation

For any skull fracture in an adult or child, in addition to treatment, a long rehabilitation period is required. While the injury is healing and for at least 6 months afterwards, the patient should not undertake any physical activity.

During the recovery period, the patient is advised to periodically use the Chantz collar. It is also possible to participate in sessions of magnetic and acupuncture therapy, massage and electrophoresis. The patient is recommended to attend classes with a psychologist and psychiatrist, and in some cases, classes with a speech therapist are necessary.