FRACTURES OF THE VAULT

Be sure you are familiar with the methods of controlling bleeding in Section 63.9.

INDICATIONS FOR RAISING DEPRESSED FRACTURES IN ADULTS (1) Coma, or other signs of cerebral compression. (2) Local neurological signs such as hemiplegia or aphasia. (3) A depressed fracture over the patient’s motor cortex. (4) Fragments of bone or foreign bodies in his brain. (5) Penetration of his dura. (6) Leaking CSF. (7) If a fragment is depressed by more than the thickness of his skull, say 5 mm, most expert surgeons would raise it, even if there are no other indications for doing so. If it is causing the patient no symptoms, you, who are less expert, would be wise to leave it. (8) If a fracture is open, this is a strong indication for raising it, and, if necessary, removing the fragments which may promote Infection.

CONTRAINDICATIONS (1) Depressed fractures over a sinus (63.9) without neurological signs. (2) Very large closed depressed fractures. Most experts would operate on these.

WHEN TO OPERATE? if a patient has more serious injuries elsewhere, you can, if absolutely necessary, leave his depressed fracture for up to 24 hours or longer. This is provided you toilet and close his scalp wound and provided his dura is not damaged.

X–RAYS Look carefully at these to see if the patient’s sagittal or lateral sinuses are in danger. If they are, expect severe bleeding.

PREPARATION Shave all the hair from his scalp.

ANTIBIOTICS In the hope of preventing infection, give the patient an antibiotic which will enter his CSF, such as suphadiazine 2 g followed by 1 g 4 hourly, or chloramphenicol. Also, give him penicillin; start immediately, and don’t continue antibiotics beyond 5 days.

EQUIPMENT A general set, preferably two general sets, so that you can use the second one when you are inside his skull. Hudson’s brace, a perforator, and burrs. A fine suction tube. A malleable copper retractor. A bottle of warm sterile saline and a drip set arranged so that you can irrigate the wound to wash away blood and damaged brain.

ANAESTHESIA If possible, give the patient a general anaesthetic (A 16.8).

Local anaesthesia is also possible. The skull, the dura, and the brain are insensitive to pain, so you need only anaesthetize the patient’s skin. Before you inject the anaesthetic, test the mobility of his scalp, and plan carefully how you can best cover his wound subsequently. You may need to swing flaps to close the incision. Add adrenaline to the anaesthetic solution to control the bleeding. Inject it well beyond the edges of his wound, wherever you expect to incise.

Arrange to minimize venous bleeding by adjusting the slope of the table, and carefully positioning the patient’s head and neck as in Section 63.9.

PREPARING THE PATIENT’S OUTER THIGH Always prepare and towel the lateral aspect of his thigh, so that you can quickly take a piece of his fascia lata to repair a torn sinus or a gap in his dura. Take it as in Fig. 63-17. Be sure to take it from the lateral aspect—there is little fascia anteriorly.

THE SCALP INJURY Toilet and explore this to remove all visible dirt as described in Section 63.7.

If the patient’s scalp wound is small, excise any very ragged edges, sew it up, and turn down a separate U–shaped flap with its base facing downwards. Make this flap carefully and use the methods in Section 63.9 to prevent excessive bleeding.

If there Is a gap in his scalp, you may be able to close it by using one of the sliding flap methods (Fig. 63-15).

Explore the surface of his skull thoroughly. If you find a fissured fracture, leave it, unless it is leaking CSF, or is filled with dirt. Remove all dirt and contaminated periosteum.

RAISING A DEPRESSED SKULL FRACTURE

Discard the instruments you have used for the skin, and take a fresh set.

Insert a self retaining retractor, to improve the exposure. Strip the patient’s pericranium away from the depressed bone, starting at the edge of the depression. Then strip it off the surrounding bone, as far as the edges of the wound. Make a burr hole in sound bone of his intact skull, close to the edge of the depressed area. If there is a choice, make it over a silent area in his brain. Start with a perforator, and use the brace and burrs as in Fig. 63-10.

CAUTION! Don’t make the burr hole in the depressed fragment. It may be loose and go straight into his brain with the burr.

Enlarge the hole with bone nibblers. Before you insert them, push his dura away from the inner table with a dural separator.

Occasionally, you will be able to insert a bone elevator and lever up the depressed fragments, as in Fig. 63-16. More often, you will have to remove them piece by piece as in Fig. 63-18. Remove all loose or grossly contaminated fragments. If they are clean, lay them back on the surface of the dura. They will act as a graft, and help to close the bony defect.

If the fragments are locked, you may have to make a second burr hole to unlock them.

If the fragments are very large, expose the fracture widely with large skin flaps which must have an adequate base. Lift up the fragments, and suture them in position with stitches through the pericranium.

If a clean fragment remains attached to the patient’s pericranium, leave it.

If the surrounding edges of the patient’s skull are dirty, nibble them away.

CAUTION! If there are any fragments in or near a venous sinus, leave them. It may bleed torrentially if you try to remove them.

THE DURA IN A FRACTURE OF THE VAULT OF THE SKULL

If the patient’s dura is intact, leave it, remove any extradural haematoma present, and close the wound.

If his dura is blood stained or CSF oozes from the burr hole, his dura has been torn. Expose the whole tear by nibbli ng away more bone to expose 2 cm of intact dura all round it. This will allow you to see any laceration in his cortex.

If the tear in his dura has ragged edges, cut them away. If necessary, enlarge the tear. The bony fragments responsible for the tear are usually near the surface of the brain. Remove them.

If his brain is uninjured, close his dura with interrupted stitches of fine monofilament and close the wound.

If part of the patient’s dura has been lost, you cannot close it by simple suture, so sew a piece of pericranium or fascia lata in place with fine monofilament. For small gaps use pericranium, for large ones use fascia lata. Trim the edges of the dura, then trim the patch to fit the gap exactly, and sew it in place edge to edge.

If his dura is purple and bulging, stroke its surface with the point of a No. 11 scalpel blade. As soon as it is opened, enlarge the opening with fine scissors, to expose the blood clot.

THE BRAIN IN A FRACTURE OF THE VAULT OF THE SKULL

If necessary, get a better view of a patient’s brain by nibbling away more of his skull and opening his dura wider. Handle his brain gently. Remove all the dead tissue, clot, bone fragments, and foreign bodies that you can reach.

Remove any damaged brain tissue with a jet of warm saline from a syringe or by suction. Fix a rubber catheter on the end of the sucker and gently suck out any blood clots or purple damaged brain. Provided the nozzle of the sucker is not too wide, it will suck away soft injured brain safely, without injuring normal brain. Foot suction is usually safe. Stroke the surface of his brain with a fine suction tube until you get to healthy tissue. If you are not sure how much brain to remove, take away too much rather than too little.

When the toilet is complete, there should be a clean hole in his brain. It will close up and become smaller.

If there might be a foreign body in the patient’s brain, insert brain retractors, suck and look. If you know where it is because you can see it on an X–ray, explore very gently with fine dissecting forceps. You can usually find and remove it quite easily. Or, you may be able to remove it on the end of a sucker. Don’t try to feel it with your finger, you may push it further in. If you cannot remove it easily, leave it. You may have to leave a deeply embedded bullet, but try to remove a large deep bony fragment.

CAUTION! Keep the patient’s exposed brain wet with saline.

Control bleeding by the methods in Section 63.9.

CLOSING THE DURA IN A FRACTURE OF THE VAULT OF THE SKULL

When you have controlled all bleeding inside the patient’s dura, close it, if closure is easy. Otherwise graft it. If necessary, hitch the dura to the pericranium as in Fig. 63-19.

The wound should be perfectly dry before you close a patient’s skull, especially after an extradural haemorrhage, and when his brain has not completely expanded. If it is not dry, a clot will form postoperatively, and bleeding will not stop until the tension in it raises sufficiently to cause undesirable pressure on his brain.

CLOSING THE WOUND IN A FRACTURE OF THE VAULT OF THE SKULL

Ask an assistant to close the patient’s thigh wound, while you close his head. Most scalp wounds heal by first intention, and delayed primary suture is seldom necessary. Close them with the stitiches in Fig. 63-14.

CAUTION! Accurate closure of the skin wound without tension is most important. If necessary cut flaps (Fig. 63-15).

Continue penicillin, sulphadiazine, and chloramphenicol for 5 days.

DIFFICULTIES WITH A FRACTURE OF THE VAULT OF THE SKULL

If a WOUND HAS LEFT A GAP IN A PATIENT’S SKULL suggest that he wears a helmet if his occupation is such that his head might be injured. If his skull defect is over a prominent convexity, repair may be necessary.

If you DON’T HAVE A BONE NIBBLER and the patient has a fissured fracture which is leaking CSF, do a careful wound toilet and close his skin. Or, you can plug a fissured fracture with a piece of his temporalis muscle to prevent his CSF leaking out. If there is enough space for CSF to leak out, there will be enough space for you to push some muscle in. So explore and toilet his scalp wound. Take a piece of his temporalis muscle, crush it and force it into the fissure. Then close his skin wound, and give him antibiotics.

If he has a BULLET WOUND toilet the entry and the exit wounds, and suck out the clot together with any pulped brain. If the wound is deep, pass a rubber catheter along its path. Control bleeding with hydrogen peroxide packs.

If the bullet comes out easily, extract it together with any foreign bodies or pieces of bone that you can remove without too much difficulty with fine dissecting forceps. But, if the bullet is difficult to remove, toilet the superficial parts of the wound carefully, and leave it where it is. Close the wound (Fig. 63-14), and give the patient antibiotics. A bullet makes a smaller wound on entering the skull than on leaving it, and fractures the inner table more severely than the outer one. Remove any bony fragments in the brain; these must come out, the bullet need not.

CAUTION! 20 vols hydrogen peroxide produces 20 times its volume of oxygen, so make sure that there is a space for the oxygen to come out, or it may compresss the brain. Inexpert surgeons would be wiser not to use it.

If a FRACTURE HAS ENTERED HIS FRONTAL OR ETHMOID SINUSES, do nothing if the posterior wall of the sinus is intact. But if it is fragmented and torn, so that he has rhinorrhoea, he is in danger of meningitis, a brain abscess, or a pneumatocoele. Treat him conservatively with antibiotics, and he will probably recover. If a pneumatocoele develops, or CSF continues to leak for more than two weeks, refer him.

If a patient has a penetrating injury and PRESENTS LATE WITH MOTOR WEAKNESS ON THE OPPOSITE SIDE, he has escaped the immediate danger of meningitis, and he probably now has a cerebral abscess. Refer him if you possibly can. If you cannot refer him, all you can do is to explore the wound, and open his dura and his brain. Syringe out the abscess cavity with a jet of saline, and close his wound as above.