However, it is important to recognize that congenital or acquired thinning or absence of portions of the bony skull base may be identified and may not necessarily correspond to the site of csf leak. Management of temporal bone trauma pubmed central pmc. Anterior skull base fractures are relatively common traumas but surgical indications are still discussed subcranial approach seemed successful in the management of all frontobasilar fractures with reasonably low complication rate 1. Surgical anatomy n the bony architecture of the skull base can be divided into three depressions. A skull fracture is a break in one or more of the eight bones that form the cranial portion of the skull, usually occurring as a result of blunt force trauma. Early evaluation of skull base fractures and related complications has been discussed in many articles, but the timing of surgical interventions for basal skull. Comminuted fracture this refers to a complex fracture with bone splintering and tearing of the skin. The diagnosis of a base of skull fracture and any resultant csf leak can be challenging. Diagnosis and treatment of cerebrospinal fluid rhinorrhea. Pdf analysis and clinical importance of skull base. Get a printable copy pdf file of the complete article 698k, or click on a page image below to. Subcranial approach seemed successful in the management of all frontobasilar fractures with reasonably low complication rate 1.
Although in some cases, there were also nasal, maxillary, temporal, zygomatic, and frontal bone fractures, the only type of fracture that. Most of the patients with occipital condylar fracture, especially with type iii, are in a coma and have other associated cervical. Skull base trauma encompasses injury to the neurovascular and bony elements of the orbital plate of the frontal bone, the cribriform plate of the ethmoid bone, the sphenoid bone, the squamous and petrous temporal bone, and the suboccipital bone. What are the signs and symptoms of basilar skull fracture.
Nasotracheal intubation in the presence of frontobasal. Most skull fractures will heal within 36 months no evidence based return to play guidelines return to play will depend on fracture, age and sport underlying vascular injury may delay rtp longer than fracture simple linear fractures may return to exercise as soon as symptoms allow high risk activity should be. They may occur in isolation or often in continuity with skull vault fractures or facial fractures. Usually, the question will show you some racoon eyes or a bruised mastoid, and then ask what other problems might be associated with a base of skull fracture. Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. An occipital bone fracture is said to occur when the saucershaped bone at the base of the skull gets fractured. With changing trends in hi, there is a need to reassess incidence and pattern of bsf pattern, csf leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking. Subjects all patients in our trauma database with radiographic evidence of a skull base fracture from january 2010 to. Basilar fractures of the skull, also known as base of skull fractures, are a common form of skull fracture, particularly in the setting of severe traumatic head injury, and involve the base of the skull. Basilar skull fracture an overview sciencedirect topics. A skull fracture is serious because there is a risk that the brain may be damaged either directly by fractured bone from the skull or by bleeding inside the skull.
Ring fracture definition of ring fracture by medical. Professor and chairman of neurosurgery jordan university medical school and hospital 2. Complications of skull base fractures such as intracranial vascular injuries, nerve injuries, leptomeningeal cyst formation, cerebrospinal fluid fistulas, craniocervical instability, hematomas, and iatrogenic cerebral parenchymal injury are described, and the. Traumatic fracture of the skull base may also cause perforation of the leptomeninges, sometimes allowing csf to flow from the subarachnoid space out of the nose or ear. Meningitis is a complication in about 14% of cases. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%. To properly describe, diagnose, and classify traumatic neck and skull base injuries, radiologists should be familiar with the neck and skull base anatomy and imaging findings associated with these injuries at ct and ct angiography. Skull base trauma csf leak basilar skull fracture csf rhinorrhea key points skull base fractures are managed based on associated intracranial injury and complications, including vascular and cranial nerve injury and cerebrospinal fluid csf leak. There are many types of skull fractures, but only one major cause. Management of the head injury patient william schecter, md. The risk of developing an intracranial complication after head injury is greater in those who have sustained a skull fracture. Controversies in the management of skull base fractures and. Traumatic neck and skull base injuries radiographics.
Endoscopic surgery for any type of skull base defect is the gold standard. Treatment of injuries of the skull base, chapter 17, p. Fractures of the basis cranii are usually the result of extension of a vault fracture. Open fractures communicate with the skin through a wound, a sinus, the ear, or the oropharynx.
Fracture at the base of the skull periorbital hematoma battles sign. Aug 30, 2017 a skull fracture is any break in the cranial bone, also known as the skull. Controversies in the management of skull base fractures and related complications have gained little attention in medical practice. According to one retrospective study of 207 headinjured patients, 37 percent of those with associated intracranial pathology sustained a linear skull fracture. It is divided into anterior, central, and posterior regions, which form the floor of the anterior, middle, and posterior cranial fossae. Such patients are often unable to give a good history, through reduced consciousness.
Its timely diagnosis requires clinical, radiographic, and laboratory testing. Base of skull fracture comes up a lot in the cicm fellowship exam. If the force of the impact is excessive, the bone may fracture at or near the site of the impact and cause damage to the underlying structures within the skull such as the membranes, blood vessels, and brain. Surgical options include direct insertion of a subdural drain connected to an underwater seal or, indirectly, with the use of a salineprimed camino bolt. Most common causes include a fall, a traffic accident, or an assault. They occur in 24% of head injuries and are often related to brain injury in 50% of the. This article outlines the pathophysiology, diagnosis, and management or csf leak of the anterior skull base. The parietal bone is most frequently fractured, followed by the temporal, occipital, and frontal bones.
This may take up to 6 months to develop, resulting from the brain pulsating against a dural defect that is larger than the bone defect. Management of anterior skull base cerebrospinal fluid leaks. Basis cranii fracture pdf skull base fractures are of high importance in neurotrauma. The temporal bones are paired structures located on the lateral aspects of the skull inferior to the parietal bones, posterior to the sphenoid bone, and anterior to the occipital bone fig. The incidence of skull fractures among head injured adults who present to emergency departments ed is unknown. Extensive traumatic anterior skull base fractures with. A skull fracture is any break in the cranial bone, also known as the skull. They are categorised according to the appearance, location, degree of depression, and according to whether they are open or closed. Skull base fractures and their complications radiology key. Classification and management of skull base fractures.
Due to the presence of blood vessels and nerves at the base of the skull, fractures in this area are often accompanied by complications arising from damage to these tissues 5. Jan 11, 2020 basis cranii fracture pdf skull base fractures are of high importance in neurotrauma. Given the comminution and medial and lateral anterior skull base involvement, this is a type iii. Open fractures are often serious because theres a higher risk of bacterial infection if the skin is broken. The surgery was successful in seven out of nine patients in the study, although one of the seven patients required a revision procedure. Base of skull fracture litfl ccc traumatic brain injury. In conclusion, patients with basal skull fracture who develop. Axial ct image demonstrating a comminuted and displaced transversely oriented anterior skull base fracture arrows extending across the orbital roofs and ethmoid roofs, with involvement of the lateral orbital walls.
Many authors have discussed prophylactic antibiotic therapy for csf fistulas caused by basal skull fractures, but there has not been a standardized protocol for csf leak management. An annular bone fracture at the base of the posterior fossa around the foramen magnum, which is accompanied by compression fractures of vertebrae and blunt trauma to soft tissue. She co pain behind r ear, tinnitus, dizziness, and slurred speech. Trauma doctors care about recognising these because they indicate significant head trauma, and potential brain injury. Anterior cranial fossa fractures, particularly comminuted and oblique frontobasal fractures, are. If the force of the impact is excessive, the bone may fracture at or near the site of the impact and cause damage to the underlying physical structures contained within the skull such as the membranes, blood vessels, and brain. An affected casualty may have impaired consciousness. This is a basic article for medical students and other nonradiologists skull fractures usually occur following significant head injury and may herald underlying neurological pathology. A study by lemonnier et al indicated that endoscopic endonasal eustachian tube closure is an effective management technique for refractory csf rhinorrhea occurring after lateral skull base surgery. They are categorized according to the appearance, location, degree of depression, and if they are open or closed. Most of these fractures 90% are secondary to closed head trauma.
Base of skull fracture radiology reference article. Skull fractures summary radiology reference article. In contrast, those groups that suffer multiple or large fractures and a broad or multifocal injury, as well as those that are victims of penetrating injury with significant comminuting fractures of the skull base, represent the most difficult groups to treat. Clinical signs of skull base fracture include anosmia, bilateral periorbital ecchymosis, hemotympanum andor perforation of the tympanic membrane, facial palsy, hearing loss, nystagmus, vertigo, cerebrospinal fluid csf rhinorrhea or otorrhea, and ecchymosis over the mastoid prominence, also known as a battle sign. The temporal bones form parts of the middle and posterior cranial fossae and contribute to the neurocranium or skull base. In this article, the description, classification, incidence, clinical findings, and diagnosis of skull base fractures are outlined. Linear fractures are the most common, followed by depressed and basilar skull fractures. A base of skull fracture is a break in one or more bones of the skull floor yes, thats bones plural. Dec 04, 20 a simple classification of skull fractures 1. The temporal bones form parts of the middle and posterior cranial fossae and contribute to. Skull fractures are common in the setting of both closed traumatic brain injury and penetrating brain injury. Management of csf leak in base of skull fractures in adults. Their importance is both as a marker of the severity of trauma and because they are, depending on location, associated with a variety of soft tissue injuries. Skull fractures symptoms, diagnosis and treatment bmj.
The surgery of skullbase fracture aims for restoration the normal anatomy, reconstruction of the skull base, to avoid complications i. When a growing skull fracture is diagnosed, a transcranial procedure with repair of the herniated intracranial contents and bony reconstruction is required fig. Therefore a combination of biochemical and radiological studies are needed to optimise the diagnosis of this condition. Pathophysiology of iatrogenic and traumatic skull base injury. The skull base is made up of 7 bones, the paired frontal and temporal bones, and the unpaired ethmoid, sphenoid, and occipital bones. The surgery of skull base fracture aims for restoration the normal anatomy, reconstruction of the skull base, to avoid complications i. Skull fractures may be linear or comminuted with multiple fracture lines, may be located on the cranial vault or in the basilar skull, may have a varying degree of depression or elevation, and can be open or closed. Return to play after skull fractures and intracranial bleeds. Undisplaced or minimally displaced clavicle fracture. Aims and objectives basal skull fracture bsf is rare in head injury hi patients and occasionally goes unnoticed which may lead to cerebrospinal fluid csf fistula. Skull fracture epidural hematoma subdural hematoma subarachnoid hemorrhage intracerebral hematorma cerebral contusion diffuse axonal injury. Objectives we aim to present our experience of managing traumatic base of skull fractures and our outcomes. According to another retrospective study of 2254 cases of head trauma from assault, approximately onethird sustained a skull fracture.
Occipital condylar fracture is a very rare and serious injury. Medical and surgical management can mitigate the risk of lifethreatening infection and morbidity. Wendy wright, daniele rigamonti, in cerebrospinal fluid in clinical practice, 2009. Posttraumatic csf leaks are generally treated conservatively, and a majority of them resolve without further surgical management. P14 management of traumatic skull base fractures and their. Nasotracheal intubation in the presence of frontobasal skull fracture. Surgery is recommended for the treatment of a broken occipital bone, as it is associated with an increased risk of complications. Skull fracture refers to a fracture of one or more bones of the cranial vault or skull base. Oct 31, 2014 1 presence of skull fractures is a prognostic factor for worse outcome. Laterobasal fractures, including those of the petrous bone, are usually associated with deficits of facial and vestibulocochlear nerves vii and viii.
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