skull fracture
Introduction
Introduction to skull fracture Skull fractures are more common, often due to blunt violence or penetrating injury, most of which do not require special treatment, so the fracture itself is not important, but the occurrence of skull fracture is closely related to the direction, size, and deceleration distance of violence, due to Skull fractures often involve brain, meninges, intracranial blood vessels and nerve damage. If not treated promptly, it can cause intracranial hematoma, cerebrospinal fluid leakage, intracranial infection and other complications, affecting prognosis. Therefore, timely, effective and correct diagnosis and treatment are particularly important. There are many classifications of skull fractures, which can be divided into calvarial and skull base fractures according to the location of the fracture. According to the shape of the fracture, it can be divided into linear, concave, comminuted and cave fractures. In addition, depending on whether the fracture is locally connected to the outside, it can be divided into a closed fracture and an open fracture. basic knowledge The proportion of illness: 0.002% is more common in car accidents Susceptible people: no special people Mode of infection: non-infectious Complications: cerebrospinal fluid rhinorrhea traumatic epilepsy intracranial hypotension syndrome intracranial venous sinus thrombosis post-traumatic brain fat embolism post-traumatic syndrome meningitis brain abscess ventricle inflammation
Cause
Cause of skull fracture
The role of violence (30%):
The occurrence of skull fracture is the result of the reaction force generated by the violence on the skull. If the head moves with the direction of violence, there is no reaction force, it will not cause fracture, the skull has certain elasticity, and under the quasi-static, adult skull The maximum stress relaxation when subjected to compression is 12%, and the maximum strain creep is about 11.5%. At the same time, the elastic modulus of the inner and outer plates of the skull, the sensitivity of the failure stress and the failure stress corresponding to the variability are also limited, and the anti-stretching strength is always less than the compressive strength, so when violence acts on it, Always rupture in the part that bears the tension. If the intensity of the striking is large, the area is small, and the local deformation of the skull is mostly caused. The sag fracture is often caused, and the brain damage associated with it is limited. If the area of the force is large, When the intensity is small, it is easy to cause the overall deformation of the skull, and multiple linear fractures or comminuted fractures occur, and the brain damage associated with it is also extensive.
Local deformation of the skull (20%):
When the cranial cap (the ankle) is subjected to an external force, the local part of the force is deformed, and when the external force is terminated, the skull is then bounced back. If the violence is fast, the area of action is small, and the elastic limit of the skull is exceeded. The central area is tapered into the cranial cavity, and the inner plate is ruptured by the large tension. At this time, if the violence does not continue to act on the skull, the outer plate can rebound and be reset, so it can remain intact, resulting in so-called simple Internal plate fracture is one of the causes of post-traumatic headache or chronic headache. If the violence continues to function, the outer panel will also fracture, resulting in a depression centered on the strike point and its outer ring and line shape. Fracture, if the effect of the violent injury is still not exhausted or is a high-speed powerful blow, the fracture piece is also caught in the cranial cavity, and a sag-shaped fracture or a hole-shaped fracture is formed.
Overall deformation of the skull (20%):
The bone structure and shape of the skull is like an elastic hemisphere. The skull is curved. The bottom of the skull is like a section. Just like the relationship between the bow and the string. Pressing at any point in the hemisphere can make the bow and string. It is deformed by force. For example, when the side is pressed, the left and right diameters of the skull become shorter and the anteroposterior diameter increases. Conversely, if the anterior-posterior violence often shortens the sagittal diameter, the transverse diameter becomes longer. Therefore, when the violence is lateral, the fracture line tends to be perpendicular to the sagittal line, and is folded toward the ankle and the skull base. When the violence is in the anterior-posterior direction, the fracture line is often parallel to the sagittal line, extending forward to the anterior cranial fossa, reaching the occipital bone backwards, and even causing a sagittal suture fracture in severe cases. In addition, when the weight acts vertically on the top of the head And due to the fall of the buttocks or the heel, the violence passes through the spine to the base of the skull. In both cases, whether from top to bottom or bottom-up, the force and reaction force are encountered in the large area of the occipital bone. Cause local deformation, light cause a linear fracture of the skull base, severe cases can cause life-threatening skull base ring fracture, into the brain.
Arch structure of the skull (15%):
There are some thickened parts of the skull and the skull base. As the arch and beam of the cranial cavity, it can resist the compression or stretch of the external force to a certain extent, and play a role in protecting the brain injury. Some include: nasal roots, frontal condyles, mastoids and struts outside the pillow. In the meantime, there are upper iliac crests, iliac crests, upper line and sagittal line, four bone arches in front, side, rear and top center, forming a strong arch column. The enhanced part of the skull base is: middle part The occipital slope has sphenoid bones and rock cones on both sides, forming a beam, strongly supporting the skull base, supporting the brain, and connecting with the surrounding calvarial struts, combining the cranial cavity with considerable toughness and elastic strength. Perfectly protects the nerve center. When the skull is hit, the violence will not only cause local curvature deformation of the skull, but also cause different degrees of overall skull deformation. If the violent energy is absorbed locally, it will be exhausted. It only causes a concave fracture or damage to the force. If the violent energy is not depleted and continues to act on the skull, the fracture line will extend along the weak part of the skull through the force point due to the overall deformation of the skull, that is, the fracture between the thickened arches. The regularity is not only seen in the fracture of the skull, especially in the skull base fracture. Because the thickness of the skull base is different, it contains many pores, so the fracture line often passes through the weak bone.
Regularity of skull fractures (10%):
The direction of the violent action, the speed and the area of the injury have a great influence on the skull fracture, which has certain regularity. It is summarized as follows: the force axis of the violent action and its main component direction are consistent with the extension direction of the fracture line. However, when there is a thickened skull arch structure, it is often folded to the weak part of the bone. If the fold line crosses the arch beam structure vertically, or causes the joint to separate, it means that the intensity of violence is very large, and the area of violence is small and the speed is fast. Because the local pressure of the skull is relatively large, it is penetrating, often causing a hole fracture, and the bone piece is trapped in the cranial cavity. If the striking area is large and the speed is fast, it will cause partial crushing and sag fracture. If the area of the action point is small and the speed is slow, it often causes a linear fracture through the point of force. If the area of the action point is large and the speed is slow, it may cause comminuted fracture or multiple linear fractures, and the impact perpendicular to the skull cover may cause local depression or comminuted fracture. Slanting strikes multiple linear fractures and extends in the direction of the force axis, often to the base of the skull. Injury to the occipital region often results in a fracture of the occipital bone or a fracture to the ankle and mid-cranial fossa.
Violence directly hits the plane of the skull base, except that it is more likely to cause a skull base fracture. When the force is upward, the skull can be opened. Violence acts on any part of the skull, as long as it causes a large deformation of the skull, which is prone to skull base fracture. The top of the head is stressed. The fracture line is usually vertically downward and extends directly to the adjacent skull base. When the violence is uploaded by the spine, the occipital bone fracture can occur. When the skull is squeezed, it often causes a skull base fracture. When the ankle is hit, it can cause a concave fracture of the mandibular joint, but the head can move in the direction of the force to buffer the impact of the external force on the craniocerebral junction. When the maxilla is hit, it is not only easy to cause jaw fracture, but also through the medial and horns, the violence is uploaded to the sieve plate and fracture occurs. The root canal can cause fractures of the frontal sinus and anterior fossa.
Prevention
Skull fracture prevention
Life is temperate, pay attention to rest, work and rest, and orderly life.
Complication
Skull fracture complications Complications Cerebrospinal fluid rhinorrhea traumatic epilepsy intracranial hypotension syndrome intracranial venous sinus thrombosis traumatic brain fat embolism brain trauma syndrome meningitis brain abscess ventriculitis
1. Cerebrospinal fluid rhinorrhea and ear leaks
After craniocerebral injury, the skull base fracture is accompanied by dural and arachnoid rupture at the same time. The cerebrospinal fluid passes through the injured paranasal sinus or rock bone, and flows out through the nose or ear, which forms a cerebrospinal fluid rhinorrhea or ear leak. Most cerebrospinal fluid leakage can be self-healing by non-surgical treatment, and only a few patients who are unable to heal for a long time need surgery.
2. Cranial nerve injury
Cranial nerve injury is caused by multiple skull base fractures, but also due to brain damage to the cerebral nucleus, or secondary to other diseases. Significant brain nerve damage is almost always damaged in the area of the skull through the skull base, which may directly cause nerve fracture due to fracture, or caused by traction, contusion or neurological blood supply disorder.
(1) olfactory nerve injury: 3% to 10% of patients with craniocerebral injury and olfactory nerve injury, more than half of the olfactory nerve injury is caused by direct violence of the forehead, and the olfactory nerve wire is avulsed through the sieve plate. At the same time accompanied by a paranasal sinus fracture. About one-third of patients were caused by the contusion of the frontal lobe caused by occipital force. One or both sides of the olfactory loss or loss immediately after the injury, often accompanied by cerebrospinal fluid rhinorrhea. If it is part of the olfactory disorder, it may have different degrees of improvement in the future, and abnormal smell often occurs before recovery. If the bilateral olfactory loss is sustained on both sides, it is often difficult to recover if it lasts for more than 2 months.
(2) Optic nerve injury: the incidence of closed head injury with optic nerve injury is 0.5% to 4%, and most of them are unilaterally damaged, often caused by injury of the frontal or frontal orbital, especially on the external Direct violence of the rim is often accompanied by fractures of the anterior cranial fossa and/or the middle cranial fossa. The site of optic nerve damage can be in the orbital or optic canal, or in the intracranial or optic chiasm. Immediately after optic nerve injury, the patient showed visual impairment, such as blindness, decreased visual acuity, and indirect disappearance of light reflexes in the pupil.
(3) oculomotor injury: often caused by sphenoidal winglet involvement in the anterior cranial fossa fracture, or due to the intracranial fossa fracture through the cavernous sinus, occasionally secondary to the internal carotid artery - cavernous fistula, aneurysm Or cavernous sinus thrombosis. When the oculomotor nerve is completely paralyzed, the patient will have ptosis, dilated pupils, and light reflexes after the injury. The eyeball is slightly below the lateral direction, and the upward, downward, inward movement and the function of the convergence are lost. If the system is not completely paralyzed, the ptosis and dilated pupils are lighter, but patients often have double vision, especially when gazing toward the healthy side, which can be reduced or disappeared when viewed from the affected side. If the patient is a brain stem injury, involving the oculomotor nucleus, or accompanied by an intracranial secondary hematoma caused by the sacral leaf hook back, there may also be symptoms of oculomotor nerve palsy, which should be carefully identified, the former often affects both eyes, after Patients are secondary to progressive intracranial hypertension and brain compression, and multiple tinnitus or dizziness, long-term treatment can be considered for ear surgery, destruction of the labyrinth or selective severing of the vestibular nerve.
(4) Posterior group of cranial nerve injury: the posterior group of cranial nerves are located in the posterior cranial fossa, and the chance of damage is relatively small. It is mostly caused by the fracture line and the jugular foramen and sublingual nerve holes. In severe cases, it can be accompanied by facial and auditory nerves. damage. After the glossopharyngeal nerve is damaged, the patient has difficulty swallowing, the pharyngeal reflex disappears or decreases, and the 1/3 of the tongue is lost. The vagus nerve is impaired as a soft-sacral movement disorder, and the vocal cords are paralyzed and vocal. When the accessory nerve is damaged, the affected side of the sternocleidomastoid and the trapezius tendon can be seen, and the patient has a sloping shoulder. Sublingual nerve injury atrophy of the semitonal lingual muscles, the tongue is biased to the affected side.
3. Internal carotid artery - cavernous fistula
After the injury of the internal carotid artery-cavernous sinus segment, the arterial blood directly flows into the cavernous sinus through the rupture, which forms the internal carotid artery-cavernous sinus fistula. A small number of patients can be cured after repeated compression of the carotid artery over a long period of time, but most patients require surgery. Currently commonly used treatment methods include: surgical embolization and endovascular embolization.
4. Traumatic epilepsy
Traumatic epilepsy refers to epileptic seizures secondary to craniocerebral injury, which can occur at any time after injury. Early episodes appear immediately after injury, and late episodes can occur after multiple head injuries. Traumatic epilepsy is more common in young men and may be associated with more chance of head injury. In general, the heavier the brain damage, the greater the chance of epilepsy. Open brain injury is more than closed. Short-term convulsions within 1 week after the trauma, there is no significant clinical significance, and no longer the author, no special treatment. Systemic antiepileptic medication should be given to recurrent episodes of early or intermediate epilepsy.
5. Infection after head trauma
Intracranial and extracranial infections are rare after closed head injury. The main infection is open brain injury, especially firearm injury.
(1) Scalp infection:
1 scalp abscess: acute scalp infection is mostly caused by improper treatment in the initial stage of the injury, often in the subcutaneous tissue layer infection, local red, swollen, hot, painful, swollen and tenderness of the lymph nodes before the ear, behind the ear or under the pillow, due to The scalp has a fibrous septum connected to the aponeurotic aponeurosis, so the tension in the inflammatory zone is high, and the patient often suffers from pain, accompanied by symptoms such as chills and fever in the whole body. In severe cases, the infection can invade the skull and/or the skull through the blood vessels. . The principle of treatment is to give antibacterial drugs and local hot compress in the early stage. When the abscess is formed in the later stage, the incision and drainage should be performed, and the systemic anti-infective treatment should be continued for 1 to 2 weeks.
2 Cap-like subarachnoid abscess: the subarachnoid tissue is loose, and the purulent infection is easy to spread, generally limited to the attachment edge of the cap-like diaphragm. Abscesses originate from scalp hematoma infection or skull osteomyelitis after injury, occasionally caused by scalp infusion or puncture in children. Such patients often show swelling of the scalp, pain, eyelid edema, and severe systemic toxic reactions. In the treatment, in addition to the application of antibacterial drugs, drainage should be cut in time.
3 osteomyelitis: acute osteomyelitis in the cranial cap often manifests as scalp edema, pain, local tenderness, and when the infection spreads to the periosteum of the outer skull of the skull, a baud edema mass may appear. In the early stage, the disease was easily overlooked. On the X-ray film, only signs of decalcification and destruction were observed after 2 to 3 weeks of infection. Chronic cranial osteomyelitis, often manifested as a long-lasting sinus, repeated ulceration, sometimes can discharge the dead bone fragments. At this time, the X-ray film is more likely to show the uneven bone density of the worm-like density. In the meantime, the density of the flaky dead bone image is sometimes seen. In some cases of chronic skull osteomyelitis, bone can also appear around the damaged area. Hardening and hyperplasia can be confirmed by X-ray film. For the treatment of skull osteomyelitis, surgery should be performed at the same time as antibacterial therapy to remove the diseased bone that has lost vitality and no blood supply.
(2) epidural empyema: skull osteomyelitis is more likely to be associated with epidural empyema, and sometimes due to incomplete debridement after open skull fracture, when the scalp wound has often healed. Early onset patients have headaches, fever, etc. After the formation of abscess, there may be symptoms of increased intracranial pressure and local brain tissue compression, such as hemiplegia and aphasia. CT examination showed that a fusiform image resembling an epidural hematoma appeared at a low density in the early stage, and gradually changed to an equal density or high density shadow after one week. Due to the inflammatory granulation hyperplasia of the dura mater in the lesion area, the concave dura mater is significantly enhanced, showing a characteristic dense curved band.
Extradural empyema should be treated surgically to remove epidural pus and granulation tissue. Patients with osteomyelitis must be removed at the same time. For epidural empyema near the superior sagittal sinus or transverse sinus, the thrombus should be alert. Sinusitis. Generally, after the abscess is removed, the antibacterial treatment should be continued for 3 to 4 weeks, and at the same time, anticoagulant therapy should be given as appropriate to prevent venous sinus thrombosis.
(3) subdural empyema: subdural empyema often secondary to severe sinusitis, can also occur after cranial osteomyelitis or penetrating traumatic brain injury. In the early stage of the disease, patients often have headaches, fever and neck stiffness. Symptoms of increased intracranial pressure may occur later, and most patients lack neurological signs and are more likely to be missed. A small number of patients may suffer from brain compression due to a large subdural empyema, or neurological dysfunction due to cortical surface venous thrombosis, such as hemiplegia, aphasia or hemianopia.
It is generally recommended that the treatment of subdural empyema should be performed by drilling drainage and rinsing, that is, drilling in the center and lower part of the empyema area, cutting the dura mater, excluding the pus, and placing the catheter (using the catheter) ) Rinse slowly with antibiotic solution. Indwelling catheters, routine drainage, irrigation and administration. Systemic application of antibiotics.
(4) meningitis: meningitis after craniocerebral injury is more common in patients with skull base fracture and cerebrospinal fluid leakage, or caused by open brain injury. In addition to the open wound, the path of purulent bacteria into the subarachnoid space can also enter from the blood, respiratory tract, paranasal sinus and mastoid area or even the sella. Patients with acute phase often have headache, nausea, vomiting, general chills, elevated body temperature, meningeal irritation and neck stiffness. However, there are also a small number of patients with occult infection, such as recurrent intracranial infection caused by cerebrospinal fluid leakage.
For the treatment of bacterial meningitis, the pathogens should be promptly identified, and strong antibiotics that can pass through the blood-cerebrospinal fluid barrier should be applied as soon as possible. In the case of systemic administration, intrathecal antibiotics should be used.
(5) ventriculitis: traumatic ventriculitis is bacterial ventriculitis, mainly seen in brain penetrating brain injury, especially in patients with early cerebral penetrating injury, incomplete debridement, or secondary to meningitis, brain abscess. Mild ventriculitis, no clinical manifestations, its symptoms similar to meningitis, often overlooked early. Therefore, after routine treatment of patients with meningitis, there is no corresponding improvement in clinical symptoms and laboratory tests, and even if the condition is aggravated, the possibility of ventriculitis should be considered. Severe ventriculitis is an acute onset, often with high fever, paralysis, disturbance of consciousness and changes in vital signs, and even cerebral palsy. Due to the sudden collapse of the brain abscess, a large amount of pus enters the ventricular system, which can cause a strong autonomic nervous response, which is characterized by high fever, coma, sputum dilated, blood pressure drop, respiratory failure and circulatory failure, and treatment is extremely difficult.
The treatment of bacterial ventriculitis is similar to meningitis. The pathogenic bacteria should be ascertained as soon as possible, drug sensitivity test should be carried out, and strong antibiotics and drugs that can penetrate the blood cerebrospinal fluid barrier should be selected for early administration. If the ventricular system is not obstructed, the selected antibacterial drugs are effective and the infection can often be controlled. If the ventricular system is obstructed, or the antibiotics are less effective, the ventricle puncture drainage should be repeated at the same time as the systemic administration, and intraventricular administration, if necessary, double-tube irrigation and drainage.
(6) Brain abscess: Brain abscess after trauma is more related to broken bone fragments or foreign bodies. In the firearm penetrating injury, the contaminated shrapnel residue is more likely to cause infection than the high-speed shot. In addition, shrapnel and bullets are injected through the maxillofacial region, paranasal sinus or deafness, mastoid air chamber, etc., and the incidence of infection is significantly increased.
The treatment of traumatic brain abscess is basically the same as that of otogenic or blood-borne brain abscess. It is still in the stage of purulent encephalitis before the abscess has formed. Non-surgical methods can be used to give large doses of potent antibiotics.
6. Other complications
(1) intracranial hypotension syndrome: After craniocerebral injury, intracranial pressure increased to varying degrees, but a small number of intracranial pressure decreased. Some also have an intracranial pressure rise in the early stage after the injury, and later become an intracranial hypotension. Lumbar puncture pressure is generally below 80mmH2O, can be diagnosed as intracranial hypotension syndrome, patients may have severe symptoms such as dizziness and headache, after the exclusion of cerebrospinal fluid pathway obstruction, can be diagnosed as intracranial hypotension syndrome.
(2) venous sinus thrombosis: in the case of closed craniocerebral injury, the intracranial sinus can be damaged by the penetration or compression of the fracture piece, often secondary to venous sinus thrombosis. Sometimes the damage is mild, and even the surface of the sinus does not show obvious changes, but it can also occur due to factors such as blood concentration, slow blood flow and enhanced blood coagulation mechanism. The sagittal sinus is more common in the affected area, and other sinuses occur less.
(3) brain fat embolism: craniocerebral injury combined with limb fractures, secondary brain fat embolism is not uncommon. Most of the fat in the bone marrow cavity after the long bone fracture is caused by the cerebral blood vessels. A small number of obese patients suffer from a large area of crush injury. Fat enters the blood circulation through the vein or lymphatic tube to form a fat embolus. embolism.
(4) Post-traumatic syndrome: It refers to several months or years after concussion or mild brain contusion, there are still some symptoms, but there is no positive sign in the nervous system examination. Clinically, there are many different diagnostic names, such as "post-traumatic brain syndrome", "concussion sequelae", "brain trauma sequelae" and "traumatic neurosis".
Symptom
Symptoms of skull fracture Common symptoms Skull fracture sensory disturbance Increased intracranial pressure Brain injury After headache Cranial nerve damage Eyeball coma Cerebrospinal fluid Rhinorrhea intracranial calcified shock
1. Craniofacial fractures There are many forms of calvarial fractures. In addition to openness and some concave calvarial fractures, clinical signs may show direct signs of fractures. Closed fractures often only show indirect signs of fractures. It depends on X-ray examination.
(1) Clinical manifestations of closed cranial cap fracture: swelling of the scalp at the fracture site, conscious pain, and tenderness, surface of the linear fracture, often scalp contusion and scalp hematoma, obvious swelling of the diaphragm, increased tension and tenderness, often It is a sign of humeral linear fracture combined with submucosal congestion. Traumatic cranial suture is common in children. In the early stage, strip scalp hematoma along the cranial suture can occur, subperiosteal hematoma or rapid formation of huge subarachnoid hematoma. It is often suggested that there are fractures of the skull in the deep face. The depressions often occur in the forehead and the top. The injured part is often accompanied by scalp contusion and hematoma. The palpation often touches the bone subsidence, and there may be a floating feeling or bone rubbing. However, avoid repeated, violent operation, should not expect to obtain this sign as a basis for diagnosis, and increase the risk of hard brain tissue damage and even bleeding, in the simple scalp hematoma palpation, often have a central concave feeling, easily misdiagnosed as a depressed fracture At this time, it is necessary to take a tangential slice of the skull to identify it. Some people think that when the depth of the skull is less than 1cm, there is no dural laceration, and when the depth of the concave bone is more than 2cm, Highly suspected presence of dural laceration.
The sag fracture may have corresponding stimulating or damaging symptoms in the cortical functional area. The sinus fracture may cause fatal hemorrhage on the sinus or increase the intracranial pressure caused by the venous sinus. The extensive sag fracture may also cause the volume of the cranial cavity to be reduced. Increased intracranial pressure.
(2) Open cranial cap fractures: mostly occur in sharp injuries, a few are firearm injuries, and the injured scalp is full-thickness rupture. There are various types of skull fractures underneath, and various foreign bodies can be found in the wound. Such as hair, broken bone pieces, soil and cloth, etc., such a fractured dura mater is completely called "open skull fracture", when the dura mater also has rupture, it is called "open brain injury", involving the large sinus The comminuted fracture can cause fatal bleeding.
2. Skull base fractures Skull base fractures are mainly linear fractures, because the fracture line often leads to the paranasal sinus or the rock bone mastoid air chamber, which is connected with the nasal cavity or the external auditory canal respectively, also known as the internal open fracture. Although the performance is an indirect sign of fracture, it is an important basis for clinical diagnosis.
Skull base fractures are divided into cranial anterior fossa fractures, middle cranial fossa fractures and posterior fossa fractures according to their location. The clinical manifestations are characterized by the following.
(1) Clinical signs of anterior cranial fossa fracture: the forehead skin has contusion and swelling, and there are often different degrees of nose and mouth bleeding after injury, sometimes due to blood swallowing into the stomach, and vomiting black-red or brown liquid, such as the skull Cerebrospinal fluid rhinorrhea occurs when the bottom of the fossa fractures tears the meninges and nasal mucosa of the skull. The cerebrospinal fluid is often mixed with blood, but it is reddish. It is dripped on the absorbent paper, and the cerebrospinal fluid is tested by sugar-containing urine glucose test paper. Leakage can be aggravated by coughing, struggling and other factors. Occasionally gas enters the cranial cavity from the paranasal sinus through the fracture line, and the gas is distributed in the subarachnoid space, brain or ventricle, called "traumatic intracranial gas accumulation". Cerebrospinal fluid rhinorrhea usually stops spontaneously several days after the injury.
Late onset subcutaneous ecchymosis of the eyelids after injury, commonly known as "panda eye" sign, bleeding due to the limitation of the fascia, and less extended beyond the gingival margin, and often bilateral, should be directly soft tissue with the orbital Contusion identification, after the dome fracture, intra-orbital hemorrhage, can also make the eyeball prominent, such as bleeding under the conjunctiva from the posterior and forward, blood spots are often fan-shaped distribution, the base is located inside and outside the sputum, the posterior boundary is unknown, and the tip is pointed The cornea and pupil are also often bilateral. When examined, the blood spots of the cornea do not move. This feature can be distinguished from the intraocular membrane bleeding caused by the direct-eye contusion-induced ball-bound membrane.
The fracture line involves the sieve plate, and the tearing of the olfactory nerve leads to loss of olfaction. When the fracture line passes through the optic nerve hole, the vision may be reduced or lost due to injury or compression of the optic nerve.
Cranial anterior fossa fractures are also often associated with brain contusion and laceration of the frontal and frontal lobe, as well as various types of intracranial hematoma.
(2) Clinical signs of mid-cranial fossa fractures: clinically, the soft tissue swelling of the ankle is common. The fracture line is mostly limited to one side of the cranial fossa, and sometimes the sphenoid body reaches the contralateral cranial fossa. When the fracture line involves the humerus In the rock department, the facial nerve and the auditory nerve are often damaged, peripheral facial paralysis, hearing loss, dizziness or balance disorder occur. For example, when the fracture line passes through the middle ear and accompanied by tympanic membrane rupture, ear bleeding and cerebrospinal fluid otorrhea are generated, and occasionally the fracture line is wide and the external auditory canal It can be seen that there is liquefied brain tissue overflow, which should be carefully examined in clinical practice to exclude the illusion caused by the laceration of the external auditory canal wall or the leakage of facial and maxillofacial hemorrhage into the external auditory canal. If the tympanic membrane of the rock fracture remains intact, the eardrum can be found blue. Purple, blood or cerebrospinal fluid can flow through the eustachian tube to the nasal cavity or oral cavity, and attention should be paid to the identification of cerebrospinal fluid leakage associated with ethmoid sinus or sphenoid sinus fracture.
The fracture line passes through the sphenoid bone and can damage the internal carotid artery to produce the internal carotid artery-cavernous sinus fistula, which is characterized by continuous murmur of the head or ankle, pulsating eyeball protrusion, restricted eye movement and progressive vision loss. The injury can also form a cavernous sinus segment of the internal carotid aneurysm. After the aneurysm rupture, the internal carotid artery-cavernous sinus fistula is formed. Sometimes the internal carotid artery injury or the traumatic internal carotid aneurysm suddenly ruptures. A large amount of bleeding passes through the fracture gap and the sphenoid sinus To the nasal cavity, a fatal nasal bleeding occurs. If it is not decisive, the common carotid artery is quickly controlled and ligated, and the patient will die from hemorrhagic shock.
When the supracondylar fracture is fractured, the eye, the trochlear and the augmentation nerve, and the first branch of the trigeminal nerve can be injured, and the ocular dyskinesia and the forehead sensory disturbance appear, which is the supracondylar fissure syndrome.
(3) Clinical signs of posterior fossa fractures: There is often a history of traumatic trauma to the occipital area. In addition to the scalp injury at the point of stress, subcutaneous congestion can occur in the suboccipital or mastoid area after a few hours. The fracture line passes through the occipital scale. The basal part and the base part can also reach the middle cranial fossa through the humeral rock. When the fracture line involves the slope, submucosal congestion can be seen in the posterior pharyngeal wall. If the fracture passes through the internal jugular vein or the sublingual nerve hole, it can appear separately. Difficulty in hypopharynx, hoarseness or lingual tendon, fracture involving the occipital foramen, symptoms of medullary damage may occur. In severe cases, deep coma occurs immediately after injury, limbs are relaxed, breathing is difficult, and even death.
Examine
Examination of skull fracture
1. X-ray film Skull X-ray examination can determine the presence or absence of fractures and their types, and can also determine the damage of the intracranial structure according to the fracture line, and the possibility of combining intracranial hematoma, for further examination and treatment.
When the skull is taken, the general anterior and posterior and lateral slices should be taken. When there is a sag fracture, the tangential position centered on the fracture site should be taken to understand the depth of the depression. When it is suspected that the occipital fracture and the herringbone are separated, the semi-axial position of the frontal pillow or the Towne position is required. If the forehead is focused, the visual nerve hole should be taken when the visual impairment occurs on the side of the injury. When the orbital fracture is taken at the position of K., when the skull base fracture is suspected, if the condition permits, the top position should be taken.
2. CT scan of the brain CT scan using the two window positions to observe soft tissue and bone, will be conducive to fractures that can not be found in the skull flat film, especially the skull base fracture. CT scans can show the size of the fracture gap, the direction of travel, and can also show the hematoma associated with the fracture, the affected swelling of the muscle. The bone fragments that enter the brain with comminuted fractures can also be surgically treated by three-dimensional positioning of CT scans. CT scans are currently the only way to show where cerebrospinal fluid leaks. Bruce reported a 50% flat scan rate, up to 69% with an iodine cistern CT scan. When scanning, you should pay attention to different methods in different parts. It is best to use the axial position of the frontal sinus. The fracture observation of the ethmoid sinus, sphenoid sinus and middle ear tympanic cap is generally performed by coronary scanning. It should be noted that if there is a condition of injury to the spinal cord, it is not easy to use a coronary scan.
Diagnosis
Diagnosis and identification of skull fracture
diagnosis
The diagnosis rate of skull fracture through the X-ray examination of the skull is 95%-100%. When reading the film, attention should be paid to the irregularity of the fracture line and the branch, and the edge is sharp, which can be distinguished from the vascular groove of the skull. When the fracture line passes through the main meningeal artery and its branches, transverse sinus groove or sagittal midline, it should be alert to epidural hematoma. The linear fracture should also be distinguished from the cranial suture. The cranial suture has a specific part and is serrated. The projection of the inner suture is not as clear and sharp as the fracture line. Cranial suture separation is rare compared with fractures. It is common in children and adolescents. It occurs mostly in herringbone, sagittal sinus and coronal suture. It is characterized by a significant increase in cranial suture, or a misalignment or overlap of cranial sutures. Cranial suture separation can be diagnosed above or over 1.5 mm in width. The fracture of the calvarial can be a full-thickness or only the inner plate to the intracranial depression, which is a ring or a star, and the depth of the tangential slice is used to analyze the brain damage associated with clinical symptoms.
The diagnosis rate of skull base fractures by X-ray examination is only about 50%. The diagnosis must be combined with clinical manifestations. Even if the fracture line is not found in the flat film of the skull, if the clinical manifestations are consistent, it should be determined as a skull base fracture. When the fracture line passes through the frontal sinus, ethmoid sinus, sphenoid sinus and rock bone, it should be noted whether it is accompanied by cerebrospinal fluid leakage, and be alert to the possibility of intracranial infection in this type of open skull fracture. In addition, attention should be paid to the indirect signs of skull base fractures. For example, cranial fluid leakage of skull base fractures may occur in paranasal sinus and/or mastoid effusion, sinus opacity and increased density. Nasal sinus or mastoid injury, gas can occur around the skull or in the skull. If the intracranial gas is not a fracture, it is an open fracture.
Differential diagnosis
Note whether the intracranial hematoma is combined and can be diagnosed by CT scan.
