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2. Middle cranial fossa fractures present with bleeding from the ear,
(haemotympanum),orbital haematoma and CSF rhinorrhoea or
otorrhoea via the eustachian tube, ossicular disruption, (battle s
sign) or VII and VIII cranial nerve palsies. Facial paralysis could
be permanent if the 7th nerve is torn.
3. Posterior cranial fossa fractures.
They present with bruising and a boggy swelling over suboccipital
region and a patch of ecchymosis near the tip of the mastoid
process (Battle s sign). Periorbital haematomas or (raccoon eyes)
are sometimes Indication of subgaleal haemorrhage and not
necessarily signs of fracture base of skull. Repair of CSF fistula is
needed, administration of intra-venous antibiotics and close
observation.
D. Ping pong fracture of skull.
This rare type of fracture is seen in children and presents as a smooth
depression of the cranial vault, also known as a pond fracture.
E. Blow-out-fracture.
These fractures are rare and caused by fracturing the orbital walls
with herniation of orbital contents.
II. BRAIN INJURY.
A traumatic brain injury occurs when an outside force impacts the
head hard enough to cause the brain to move within the skull or if the
force causes the skull to break and directly hurts the brain.
The mechanical forces applied to the brain at the moment of injury
transfer energy to it. A relatively minor injury at the site of impact
(coup injury) and an extensive contusion of the brain opposite the
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point of impact (contre-coup injury). The majority of cases with
traumatic brain injury TBI occur among children.
Most children who sustain a TBI are treated and released from the
emergency department.
Symptoms of a TBI may not appear until days or weeks following
trauma or may even be missed as people may look fine, even though
they may act or feel differently.
The following are some common signs and symptoms of a TBI:
Irritability, depression, anxiety, headaches, dizziness, insomnia, blurred
vision, nausea and cognitive signs as concentration and orientation
problems and attention difficulties.
1. PRIMARY BRAIN INJURY
Primary occurs at the time of impact. It results in brain contusions,
lacerations, and diffuse white matter damage. The clinical hallmark of
primary brain injury is an immediate change in conscious level, their
depth and duration depend on the magnitude of the neuronal damage.
Loss of consciousness (LOC).
1. It measures the length of time between injury and when the patient
regains consciousness.
2. It is strongly correlated with outcomes in children and adults and is
a key piece of information that should be collected.
A. Cerebral concussion.
This occurs at the time of impact and is manifested by temporary
dysfunction of the brain and resolves after a variable period. It could
be accompanied by tachycardia, hypotension and sweating. Loss of
consciousness and retrograde amnesia are often common. Post concussion
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syndrome, commonly after minor head trauma, could consist of
headaches, irritability, depression, lassitude and vertigo.
B. Cerebral contusion.
This can be a result of small areas of haemorrhage in the cerebral
parenchyma. These usually cause neurological deficits that persist for
longer than 24 h, with loss of consciousness and posttraumatic
amnesia. Contusions may resolve together with the accompanying
deficit or they could persist.
Child with cerebral contusion
(Deep coma and fracture of Base of skull).
C. Brain laceration.
Brain laceration is possible even without skull fracture as a result of
rapid movement and shearing of brain tissue. The brain surface is torn
with effusion of blood into cerebro-spinal fluid.
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2. SECONDARY BRAIN DAMAGE.
This brain damage includes haemorrhage,brain swelling,damage
secondary to raised intracranial pressure, hypoxia, and infection.
* INTRACRANIAL HAEMATOMAS.
1. Intracerebral haematomas. These appear as hyperdense lesions
on CT scan with associated mass effect and midline shift as
contusional haematomas.
2. Extradural haematomas. They usually occurs as a result of
temporal bone fractures with laceration of the midline meningeal
artery. They also could arise from fractured bone edges and from
the dural venous sinuses. The degree of trauma might not be severe
and there is typically a lucid interval following the trauma.
Commonly patients with extradural haematoma present in coma
due to cerebral compression and require urgent evacuation via a
burr hole. They could have dilatation of the pupil on the side of
bleeding. The x-ray of skull may reveal fracture of anterior cranial
fossa or fracture of the temporal bone.
3. Subdural haematomas. The most common intracranial mass
lesions caused by head trauma. They are usually associated with
severe, high velocity trauma with often poor outcome in older
patients. The blood is collected in the subdural space over the
convexity of the brain and appears in the CT as a concave
hyperdense lesion. Most of subdural haematomas result from torn
bridging veins draining blood from cortex to the dura. And they
could also arise from cortical lacerations or bleeding from the dural
venous sinuses. Acute subdural haematomas are rapidly evolving
lesions and early evacuation is absolutely indicated.
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4. Chronic subdural haematomas. These type of haematomas are
commonly found in infant patients or patients over 60 years of age.
The patients come with progressive neurological deficits more than
2 weeks after the initial head trauma. The initial haemorrhage
could be relatively small and only after CT scan of the skull the
diagnosis is possible. This collection could be removed by drilling
burr holes and washing them out with warmed saline.
Subdural hematoma with pushing of the ventricle space.
Glasgow coma scale (GCS).
It is a useful indicator of severity, but not for children younger than 5
years of age.
Children s Coma Score.
It is a modification of the Glasgow Coma Score designed to be used
in children aged 5 years and younger.
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The Glasgow Coma Scale.
Function Response Score
Eye opening Spontaneous 4
To speech 3
To pain 2
None 1
Best verbal response Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys commands 6
Localizes 5
Flexes – normal 4
- abnormal 3
Extends 2
None 1
III. EARLY COMPLICATIONS OF HEAD TRAUMAS.
1- CSF rhinorrhoea.
2- Aerocoele.
3- Meningitis.
4- Acute pituitary damage and endocrine failure.
5- Fat embolism.
IV. DELAYED COMPLICATIONS OF HEAD TRAUMAS.
1- Chronic subdural haematomas.
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2- Post traumatic epilepsy.
3- Post traumatic hydrocephalus.
4- Post traumatic headache.
5- Post traumatic rhinorrhoea.
V. MANAGEMENT OF CRANIO-CEREBRAL TRAUMAS.
The majority of patients with head injuries usually does not require
any neurosurgical care and are managed by routine general surgery.
Initial assessment of head trauma patient must follow Advanced Trauma
and Life Support (ATLS) guidelines with an initial primary survey, then
resuscitation, followed by a secondary survey then definitive management.
The patient should be examined for evidence of injury e.g. lacerations
and grazes and the findings clearly documented. Skull fracture should
be excluded and the conscious level determined according the
Glasgow Coma Scale and monitored.
The following heading guidelines are considered.
1. Admission and observation.
All patients with head injuries who suffer loss of consciousness or
fracture of the skull should be admitted for observation for 24 to 48
hours,though they could be neurologically free at time of admission.
Remediable complications (intracranial haematoma) may occur following
very trivial trauma.
The main purpose of observation of a case with head trauma is to
detect surgically correctible complications. The early detection of any
cerebral compression requires careful and close watching of the
patient for any change in level of consciousness, pulse, respiration, pupils
and for signs of neurological deficit (Paralysis). Patients in coma without
haematoma require intensive care.
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Three things may happen to patients with head trauma (HT) under
observation during the first 48 hours.
1. The great majority of patients after head trauma (HT) recover with
conservative treatment and do not require prolonged hospitalization.
2. A small number of these patients after HT remain unconscious and
need further observation.
3. A very small number of cases after HT pass into progressively
deeper coma and may need special neurosurgical care.
The most important guide for the assessment of the patient after head
trauma is a change in the patient s conscious level. This could be
recorded by the Glasgow Coma Scale that is used by most neurosurgical
and emergency units nowadays. If there is deterioration in conscious
level which cannot be attributed to extracranial causes, intracranial
haematoma is suspected and the risky patient should be identified
though CT scan and prepared for evacuation surgery if indicated.
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Thoracic Trauma
Injuries to the thorax account for 25 per cent of deaths from trauma,
mainly as a result of hypoxia or hypovolaemia. 50 per cent of patients
who die from multiple injuries also have a significant thoracic injury.
According to mechanism of injuries, these are divided into blunt and
penetrating,depending on their cause. Injuries of the thorax are either
open or closed. Open injuries are caused by penetrating traumas from
knives or gunshot. Closed injuries occur after blasts, blunt trauma, and
deceleration. Road traffic accidents are the commonest cause.
Complications of closed injuries are pneumothorax, haemothorax,
intra-thoracic visceral and arterial damage, and infections.
Complications of closed injuries are rib fractures, flail segment, injury
of the aorta and its branches, myocardial contusion or rupture,
ruptured diaphragm or esophagus. Blast injuries are associated with
intra-alveolar haemorrhage, pulmonary haematoma, and hypoxia.
Historical background.
One of the earliest writings of thoracic injury was noted in the Edwin
Smith Surgical Papyrus, written in 3000 BCE. Galen reported
attempts to treat gladiators with chest injuries with open packing. In
1635, Labeza de Vaca first described operative removal of an arrowhead
from the chest wall of a Native American. In 1814, Larrey (Napoleon's
military surgeon) reported various injuries to the subclavian vessels.
Rehn performed the first successful human cardiorrhaphy in Germany
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