Fracture of the base of the skull bones
Content:
- What is a fracture of the base of the skull
- Signs and symptoms of a skull fracture
- First aid for a fracture of the skull
- Classification of skull base fractures
- Skull fracture treatment
- The consequences of a skull fracture
What is a fracture of the base of the skull
A skull base fracture is a very severe traumatic brain injury (TBI) in which one of the bones that make up the base of the skull breaks: the occipital, sphenoid, temporal, or ethmoid, or several of them. The cause of such damage usually becomes a significant impact: it can be an accident, a fall on its back from a height, a direct blow with something heavy on the head or face in the area of the lower jaw.
Fracture of the bones of the base of the skull accounts for 4% of the number of diagnosed craniocerebral injuries. A combination of fractures of the base and calvarium is also possible, which occurs in 50-60% of patients with this injury.
Skull fracture survival
Of decisive importance is how quickly and competently first aid is provided for a fracture and hospitalization with subsequent medical measures is carried out. TBI is often accompanied by profuse bleeding, which can lead to death in the first hours after injury or cause prolonged coma, for which the prognosis is extremely poor. In this case, there is a high probability of lifelong disability, when basic vital functions are impaired and intelligence is seriously affected.
With fractures without displacement, single fractures that do not require surgery, the prognosis is relatively favorable.
The mortality rate for fractures of the bones of the base of the skull ranges from 24 to 52%, depending on the severity and complexity of the injury and its subsequent complications.
Signs and symptoms of a skull fracture
Symptoms depend on the severity, location of the fracture, and the extent of damage to brain structures. Loss of consciousness can take any form, from short-term fainting at the time of injury to prolonged coma. The impairment of consciousness is the stronger, the more severe the injury, but with an intracranial hematoma, there may be a period of enlightenment preceding loss of consciousness, which should not be mistaken for the absence or ease of injury.
Common signs of a fracture include:
- Bursting headaches due to developing cerebral edema;
- Vomiting, aspiration of vomit or voluntary leakage of stomach contents into the lungs;
- Symmetrical bilateral bleeding around the eyes in the form of "glasses";
- Different diameters and lack of pupil response;
- Respiratory and circulatory disorders in case of compression of the brain stem;
- Leakage of cerebrospinal fluid (cerebrospinal fluid) mixed with blood from the nose and (or) ears;
- Cardiac disorders: arrhythmia, tachycardia, bradycardia, high or low blood pressure;
- Excitement or immobility;
- Confusion of consciousness;
- Involuntary urination.
Fractures of the pyramid of the temporal bone can be longitudinal, transverse, diagonal. With longitudinal fractures, the middle and inner ear and the canal of the facial nerve are affected. Symptoms: bleeding from the ear and secretion of cerebrospinal fluid due to rupture of the tympanic membrane, hemorrhage in the temporal muscle area and behind the ear, partial hearing loss. Bleeding worsens when turning the head, so this is strictly prohibited.
For a transverse fracture of the temporal bone, complete hearing loss, disturbances in the functioning of the vestibular apparatus, paralysis of the facial nerve, and loss of taste are characteristic.
- Clinical signs of anterior fossa fracture: epistaxis, nasal liquorrhea (secretion of cerebrospinal fluid through the nose), hemorrhages around the orbits and under the conjunctiva. Bruises appear 2-3 days after injury, which fundamentally distinguishes them from ordinary bruises that appear as a result of direct blows to the face. Sometimes the so-called subcutaneous emphysema occurs: when the cells of the ethmoid bone are damaged, air penetrates into the subcutaneous tissue, due to which bubbles form on the skin.
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Clinical signs of fracture of the middle cranial fossa: unilateral ear bleeding; a sharp decrease in hearing or complete deafness; release of cerebrospinal fluid due to rupture of the tympanic membrane, dysfunction of the facial nerve, bruising in the temporal muscle area and behind the ear; partial loss of taste. Fractures of the middle fossa account for 70% of skull base injuries.
- Clinical signs of a fracture of the posterior cranial fossa: simultaneous damage to the auditory, facial and abducent nerves; bruising behind the ears on one or both sides; when the caudal nerves are pinched or ruptured, the tongue, palate, larynx are paralyzed and the functioning of vital organs is disrupted.
- Fractures of the base of the skull are also characterized by lesions of the olfactory or optic nerve. With such fractures, the meninges rupture, as a result of which a communication channel is formed between the medulla and the external environment through the nasal and oral cavities, middle ear or orbit. Fragment fractures are especially dangerous in this regard: bone fragments can injure arteries and veins. Communication with the external environment makes the brain open to the penetration of infections and microbes and can lead to the development of encephalitis, meningitis or brain abscess.
First aid for a fracture of the skull
If you suspect a fracture, you should immediately call an ambulance. If the condition of the victim is satisfactory and he is conscious, then he should be laid on his back (without a pillow), immobilized and fixed the head and upper body, and an antiseptic bandage should be applied to the wound. In case of delay in hospitalization, dry ice can be applied to the head. If there are no problems with breathing, you can give the victim diphenhydramine or analgin.
In an unconscious state, the victim should be laid on his back in a half-turn position and slightly turned his head to one side in order to avoid aspiration in case of vomiting, unbutton tight clothes, remove existing glasses, dentures, and jewelry. To fix the body, place a roller made of clothes or blankets under one side of the body.
For acute respiratory distress, artificial respiration is done through a mask. Cardiovascular drugs (sulfocamphocaine, cordiamine), glucose solution, lasix are introduced. With heavy bleeding and a sharp drop in pressure, lasix is replaced with intravenous administration of polyglucin or gelatinol. With motor excitement, a solution of suprastin is injected intramuscularly.
Pain relievers should be used with caution, as this can complicate bleeding. The use of narcotic painkillers is contraindicated, as they aggravate respiratory distress.
Classification of skull base fractures
Fractures vary:
- According to the damaged bones of the same name;
- On the cranial fossa of the inner surface of the skull: anterior, middle and posterior;
- In relation to the external environment;
- By the presence or absence of bone displacement.
The occipital and sphenoid bones are part of the cerebral section of the skull. The temporal bones form the vault of the skull and contain the organs of hearing: in the pyramid of the temporal bone is the tympanic cavity and the inner ear. The anterior fossa is formed by the frontal bone, a plate of the ethmoid bone, separated from the middle by the edges of the sphenoid bone. The middle fossa is formed by the sphenoid and temporal bones. The posterior fossa is formed by the occipital bone, the posterior part of the sphenoid bone.
Fractures without displacement refer to open TBI and have a favorable prognosis. If the fracture is accompanied by blood loss or leakage of cerebrospinal fluid, it is considered an open penetrating TBI.
Skull fracture treatment
Magnetic resonance imaging (MRI) or computed tomography (CT) are used to accurately and accurately diagnose trauma. Depending on the severity and complexity of the injury, treatment can be conservative or operative.
Conservative treatment
Conservative methods are indicated for traumas of mild and moderate severity, when liquorrhea can be eliminated without surgery.
It is necessary to observe strict bed rest, the head should be in an elevated position - this helps to reduce the release of cerebrospinal fluid. Treatment includes dehydration therapy (aimed at reducing the fluid content in the organs), for this purpose, lumbar punctures are performed every 2-3 days (taking cerebrospinal fluid from the spinal cord at the lumbar level), subarachnoid insufflation is carried out in parallel (introduction into the subarachnoid space of the spinal cord) the same amount of oxygen. Also used are drugs that lower the production of cerebrospinal fluid - diuretics diacarb, lasix.
Physical activity is limited to six months. The victim should be registered with a traumatologist and a neurologist, observed by an otolaryngologist and ophthalmologist.
Particular attention should be paid to the prevention of intracranial complications of a purulent nature. For this purpose, sanitation of the nasopharynx, oral cavity and middle ear is carried out using antibiotics. In the presence of purulent complications, intramuscular or intravenous injections are supplemented by the introduction of antibiotics into the epidural space (endolumbar). For this, kanamycin, chloramphenicol, monomycin, polymyxin are used. Also, endolumbar administration of kanamycin is carried out 2 days after the cessation of liquorrhea. Best of all, the selection of the drug is carried out by sowing cerebrospinal fluid on the flora or a smear taken from the nasal mucosa.
Surgery
Surgical intervention is necessary in the following cases:
- Identification of a multislice fracture;
- Damage or compression of the structures of the brain;
- The outflow of cerebrospinal fluid through the nose, which cannot be stopped by conservative methods;
- Relapses of purulent complications.
Surgical treatment is used for bleeding, hematoma, or bone debris that can pose a direct threat to life. In this case, trepanation (opening) of the skull is performed, and after the operation, the bone tissue defect is closed with a removed bone or a special plate (in most cases). This is followed by a long rehabilitation.
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The consequences of a skull fracture
The consequences of fractures can be direct, immediately occurring at the time of injury, and distant. Direct consequences include:
- Intracerebral hematomas - since a fracture of the base of the skull is the result of a strong blow to the head, it is accompanied by a concussion and rupture of small, and in some cases, larger blood vessels. Small hematomas can resolve on their own, large hematomas require surgical intervention, because, being in the cranial cavity, they put pressure on the surrounding tissues and disrupt the brain;
- Infectious processes - if the integrity of the skull bones is violated, there is a high probability of pathogenic bacteria entering the wound, which leads to the development of inflammatory diseases such as meningitis, encephalitis, etc.;
- Damage to the medulla - with a comminuted fracture, bone fragments can damage the tissues and lining of the brain, which can result in hearing or vision loss, as well as breathing problems.
Long-term consequences occur after a certain period of time after the victim's recovery, most often for a period from several months to five years. They are caused by incomplete regeneration of the damaged nerve tissue, as well as the formation of scars at the fracture site, which leads to compression of the nerves and small vessels that feed the brain.
Long-term consequences can be:
- Paralysis and paresis;
- Encephalopathy and mental disorders, from partial disorientation in space to loss of self-care skills;
- Epileptic seizures;
- Severe cerebral hypertension, which is prone to malignant course, can provoke a stroke and is difficult to treat.
Author of the article: Kaplan Alexander Sergeevich | Orthopedist
Education: diploma in the specialty "General Medicine" received in 2009 at the Medical Academy. I. M. Sechenov. In 2012 completed postgraduate studies in Traumatology and Orthopedics at the City Clinical Hospital named after Botkin at the Department of Traumatology, Orthopedics and Disaster Surgery.
