63.8 Fractures of the vault of the skull

When you suspect that a patient has fractured the vault of his skull, ask yourself these questions: (1) Are the fragments depressed? Provided that his dura is not torn, you can leave most depressed fractures, which will be safer than trying to raise them. (2) Does he have an overlying skin wound? If he has, toilet it. (3) Has his dura been torn? If it has, repair it. (4) Are there any foreign bodies in the wound and particularly in his brain? If so, remove all foreign bodies from the wound. You may sometimes have to leave a bullet, or a large bony fragment deep in his brain. (5) Has his underlying brain been damaged? If it has, there is unfortunately little you can do.

Figure 63.15: MORE SCALP FLAPS. If necessary, graft the area from which you mobilized the flap. After Rowbotham.

Try to repair a patient’s torn dura. Sometimes his X–ray shows a fracture which has obviously torn it, or it may. show air in his subdural space. Often, the diagnosis is far from obvious, so don’t hesitate to explore a wound if: (1) There might be a dural tear. (2) There might be a bony fragment piercing the patient’s dura. If necessary, enlarge his scalp wound, and feel and look at his skull. You may find any of these things:

A fissured fracture should be left alone, unless it is filled with dirt or leaking CSF. CSF seldom leaks from fractures of the vault, and more often does so from basal fractures which involve a patient’s nose or ears.

If a wound in the skull is leaking CSF from a fissured fracture, make a burr hole and then nibble away the patient’s skull towards the tear, so as to expose enough of his dura to allow you to repair the tear.

A depressed fracture with fairly small skull fragments can be fatal if you try to elevate them. So, base your decision to operate on the indications given below. If you need to elevate a depressed fracture, make a burr hole in the nearby normal skull, enlarge the hole with nibblers, insert a bone elevator, and lever up the depressed fragment(s). Often, you cannot do this because they are jammed up against one another, so you have to remove them. Then, if necessary, repair the dura.

A large, closed, depressed fracture is caused by a blow from a large blunt object, and involves wide areas of the skull. A child’s skull merely bends, and the result is the ’ping – pong ball fracture’ in Section 63.8. In an adult the fragments may be comminuted, and those at the apex of the fracture may tear the dura and enter the brain. Fragments of the inner table displace more than those of the outer table, so an injury may be worse than it looks. Even with a large depressed fracture, a patient may be conscious and have no neurological signs.

Raising large pieces of bone is difficult, and you may not be able to do it through a trephine hole. So, if possible, leave them. Don’t operate merely because a fracture is depressed. If a patient has neurological signs, or a marked depression, or an obviously torn dura, refer him.

A serious consequence of an infected wound of the vault is ’brain fungus’. The patient’s brain becomes infected, swells through the gap in his skull and dura, and forms a stinking, fungating swelling on the surface of his head. Once this has happened, there is nothing anyone can do. It is the result of: (1) infection, (2) foreign bodies including bone fragments in his brain, and (3) a raised intracranial pressure. It used to be thought that the important step in preventing brain fungus was to close the dura. This is now thought to be much less important than a careful wound toilet and the removal of all foreign bodies.

If you have to leave a gap in the dura, close it with an absorbable sponge (’Sterispon’) or fascia lata from the patient’s thigh. This will lie between his brain and his scalp, both of which are highly vascular, so it will readily take and fuse with the surrounding dura. You may be able to replace the pieces of his skull, as described below, but if you cannot, this is not important.

JULIUS was walking about quite fit, smiling and gesticulating, but quite unable to speak since the previous week when he had been hit on the head in a fight. Palpation showed him to have a depressed fracture of his skull. As this was being elevated under local anaesthesia a sepulchral voice from under the drapes called out "Shikamoo" ("I am holding your feet", a local term of subservience and indebtedness). The patient went home talking volubly and everyone was happy. LESSON Aphasia is one of the indications for raising a depressed fracture.

FILIMON’S scalp was split and torn, his brains were pouring out of his head and dripping slowly to the ground. This is the literal truth. A tree had fallen on it, smashing it like an egg. On the operating table it became clear that his skull was in five pieces. As these were manoeuvred into position more brain kept oozing out. At last the jigsaw was complete and his scalp was sewn up. To everyone’s suprise he made a quick recovery and walked home. He did seem to have a rather simple and euphoric personality, but his family said that he had always been like that. LESSON Few patients are so severely injured that they must be given up as hopeless.

Both these accounts are from Leader Stirling’s ’Tanzanian Doctor’, William Heinemann, London.

Figure 63.16: DEPRESSED FRACTURES. A, a fracture which has probably not penetrated the dura. B, one which probably has penetrated it. Occasionally, you will need to elevate a ping pong ball fracture in a child, as in C. The base of this flap should face downwards (caudally) not as shown here. In an adult, you will seldom be able to do this and you are more likely to have to remove the fragments one by one, as in Fig. 63-18. Kindly contributed by Peter Bewes and Gerishom Sande.