Traumatic brain injury in children. Skull injuries

A blow to the head with great force can break the integrity of the bones of the skull. In such cases, a fracture is diagnosed. Any head injuries are serious, they are often associated with a violation of the integrity of the brain. Damage to the skull is possible not only from a blow to the head. An injury can be caused by an unsuccessful fall from a height onto the pelvis or legs.

When damaged, a life-threatening condition develops, in which hospitalization is mandatory. Based on the severity of the injury, surgical or medical treatment is prescribed.

Types of skull fractures

Skull injuries may be accompanied by a violation skin, under these conditions, an open fracture is diagnosed. Damage may be closed. The second option is diagnosed more often.

From a blow of various etiologies, the bones of the base or the vault of the skull may suffer. On this basis, fractures are divided into groups:

• If the integrity of the sphenoid, ethmoid, occipital, temporal, or several segments at once is violated, we are talking about a fracture of the base of the skull.

The mutilation is often accompanied by the formation of cracks in the bridge of the nose and orbital plates. Injuries of this nature usually cause hemorrhages in the periorbital tissue and bleeding from the nose and ears.

• A fracture of the calvarium is accompanied by the presence of a wound or depression in the area of ​​the head where the blow fell. The inner bone plate is most severely damaged, the fragments of which injure the medulla.

Trauma to the cranial vault can have a different nature of damage:

• With a linear fracture of the skull, a thin crack forms in the bone. Trauma is rarely accompanied by displacement of fragments and is one of the least dangerous injuries. Usually the bones grow together fairly quickly. The most serious complication is the formation of an epidural hematoma caused by internal hemorrhage.
• If a bone fragment is pressed into the cranial vault, we are talking about an impression fracture. In case of injury, a crush or contusion of the brain is usually formed, intracerebral hematomas are formed.
• Similar consequences are caused by a comminuted fracture. Fragments formed during trauma damage the membranes of the brain.
• A hit in the head from a firearm is the cause of an injury incompatible with life - a perforated fracture of the bones of the cranial vault. The bullet lodges deep in the brain or passes right through. Both types of injury are fatal.

Pathogenesis of injury

The mechanism of action on the bones of the skull can be both direct and indirect.

If the bone breaks at the point of impact, the fracture is called a straight fracture. If the force of the shock wave was transferred from other bones through inertia, we are talking about an indirect mechanism of damage.

A skull fracture is usually the result of a direct blow. Bones bend under the influence of force.

Fracture of the base of the skull often has an indirect character. Injury occurs from the impact of a shock wave, which is formed when falling from high altitude to the legs or pelvis and is transmitted through the bones of the spine.

Symptoms of injury

The manifestations of damage can be varied depending on the location and severity of the injury.

Linear fractures are the most common and easily treatable skull fractures. Often the injury cannot be seen on x-rays. In this case, doctors rely on external signs: a hematoma forms on the periorbital tissue, a bruise may appear in the region of the mastoid process.

A fracture of the skull, as a rule, is accompanied by a violation of consciousness of varying severity, from a short syncope that occurred at the time of injury, to a long-term deep coma. Usually the degree of manifestation of this symptom is directly related to the extent of the injury. This rule does not apply to cases where an intracranial hematoma is formed. This complication is manifested by a change in periods of clear consciousness and fainting.

If the fragments damaged the nerves of the skull or the structure of the brain, sensitivity may be impaired, up to paralysis. After an injury, cerebral edema may occur. Then the clinical picture is complemented by intense pain, nausea and vomiting.

If a fracture of the base of the skull is localized in the anterior cranial fossa, dark bruises appear on the skin around the eyes within half a day (a symptom of "glasses"). The injury is accompanied by bruising on the back wall of the pharynx. CSF mixed with blood is poured through the nose. Cerebrospinal fluid may ooze from the ears when the fracture involves the middle cranial fossa. Such signs give grounds to attribute damage to open penetrating injuries. fracture sphenoid bone leads to bleeding from the mouth and nose at the same time.

A significant part of the injuries of the base of the skull falls on fractures of the bones of the middle cranial fossa. Damage causes bleeding from one ear, hearing is sharply reduced or disappears. Cerebral fluid is poured out through the auricle if the integrity of the tympanic membrane is broken. The victim cannot keep balance and notes some loss of taste sensations.

Damage to the posterior fossa is accompanied by trauma to the brain stem, causes difficulty in breathing and bruising over mastoid processes. Perhaps the appearance of paresis of the muscles of the larynx, tongue.

IMPORTANT! A fracture of the skull in a child may initially be asymptomatic, and only after a while the general condition of the victim begins to deteriorate.

Trauma to the skull bones of any localization may be accompanied by jumps in blood pressure, malfunctions heart rate, involuntary urination. The pupils of the victim may be of different sizes, while not reacting to light.

Providing first aid to the injured

Traumatic brain injury of any severity is the basis for emergency hospitalization. If there is a suspicion of a skull fracture, before the arrival of doctors, the victim must be provided with competent first aid.

The victim, who has not lost consciousness, must be laid on a flat plane on his back and ensured that he remains motionless. The head must be fixed. If there is an open wound, it should be covered with a sterile dressing. Ice may be applied to the injured area.

IMPORTANT! When making any manipulations with the wound surface, it is necessary to avoid pressure on the injured bone.

If the injury is accompanied by fainting, the victim is laid on his side, his head is fixed with the help of rollers from improvised things. This position prevents the risk of choking on vomit. It is necessary to check the airways of the victim, in case of suffocation, artificial respiration.

It is necessary, if possible, to remove any jewelry, glasses, and dentures from the head. The collar of the garment needs to be loosened.

The victim is not allowed to take painkillers of a narcotic nature, since similar means cause respiratory failure.

Diagnosis of a skull fracture

If a person in clear mind, the diagnosis begins with a visual examination and a questioning about the circumstances of the injury. The neurological status of the patient is clarified: the doctor checks the reflexes, the reaction of the pupils, draws attention to the state of muscle tone.

The oral cavity is examined in without fail: skull fracture causes tongue deviation.

If the victim is admitted to a medical facility in unconscious, instrumental types of research cannot be applied. In such cases, based on the clinical picture of the injury, a diagnosis is made, and a treatment regimen is developed. The necessary diagnostics is carried out later, when it is possible to stabilize the patient's condition.

IMPORTANT! Damage to the ethmoid bone opens up access to air, from its penetration subcutaneous emphysema is formed.

This manifestation clearly indicates a fracture of the base of the skull and allows doctors to make a diagnosis and prescribe therapy without waiting for the results of an instrumental examination.

Treatment of a skull fracture

For the treatment of patients with skull injuries, conservative methods are most often chosen. Bed rest is the main requirement. The position of the patient should not be strictly horizontal, the outflow of cerebrospinal fluid slows down if the head is slightly higher than the body.

A skull fracture requires a lumbar puncture every 72 hours. Simultaneously, with the help of subarachnoid insufflation, oxygen is introduced, equal in volume to the extracted fluid. Dehydration therapy is also carried out with the help of diuretic drugs.

In addition to liquorrhea, the victim may experience the development of pneumoencephalitis. The accumulation of air over the hemispheres of the brain leads to sharp increase intracranial pressure. Carrying out a puncture through the superimposed milling hole allows you to remove the collected gas.

If a mild or moderate fracture of the skull bones is diagnosed, drug therapy involves taking painkillers: non-steroidal anti-inflammatory drugs are usually prescribed.

If there is an outflow of cerebrospinal fluid from the ears or nose, then the cerebrospinal fluid space is open to pathogenic bacteria. To prevent the development of a purulent infection, the patient is prescribed a course of antibiotics. Diacarb and Lasix are taken to suppress the process of producing cerebral fluid.

As a rule, an injury is accompanied by a bruise or concussion, in these cases, doctors prescribe nootropics and vasotropic drugs, as well as drugs to improve cerebral circulation.

Surgical treatment of a skull injury

If conservative methods of treatment have not had a positive effect on the outflow of cerebral fluid, there is a risk of developing recurrent meningitis. In this case, surgical intervention is prescribed, during which the CSF fistulas are eliminated. To determine the exact location of the defect, an MRI is performed with the introduction of a contrast agent into the CSF.

During trepanation of the frontal region, the lumen is covered by suturing the dura mater; in difficult cases, plastic correction aponeurosis or fascia. The bone defect is corrected by applying a piece of muscle. When liquorrhea is caused by wall injury sphenoid sinus, during transnasal intervention, tamponade is performed using a muscle or a hemostatic sponge.

Violation of the geometry of the bones of the skull can lead to damage to the optic canal. The nerve is suffering from the pressure of the hematoma. The consequences are visual impairment or total blindness. In such conditions, decompression of the optic nerve is indicated; for this, the canal is opened through transcranial intervention.

Extensive comminuted fractures require surgical treatment with cranioplasty. First, the surgeon removes sharp pieces of bone from the wound, the defect of the cranial vault is closed with a plate that is attached to the bone. A special fast-hardening plastic is widely used for the prosthesis. Tantalum plates are also used.

Urgent surgical intervention is required if an intracranial hematoma forms. The accumulated blood is removed and its source removed.

Not always antibiotics can stop the development of a purulent infection that has entered the skull after an injury. In this case, it also shows surgical treatment.

The decision on any surgical intervention is made by a neurosurgeon, based both on the diagnosis and on the general condition of the patient's body, on his age.

Subsequently, the patient requires a long rehabilitation process.

Consequences of trauma

With a skull fracture, the consequences of the injury are divided into two categories: those occurring at the time of the injury and manifesting later.

Among the direct consequences are the development of intracranial hematoma, infectious inflammatory processes, damage to brain tissue by bone fragments.

Long-term effects can manifest themselves months and even years after recovery. The scar tissue formed at the site of injury compresses the vessels that feed the brain. As long-term consequences, paralysis is formed, mental functions are disturbed, epiactivity may appear, an uncontrolled increase in pressure can provoke a stroke.

Fractures of the calvaria may be closed or open. It is observed due to domestic excesses (fights, especially blows to the head with various heavy objects), road injuries, falls from a height, often in drunkenness, industrial injuries. The bones of the cranial vault can be damaged by the type of incomplete fracture, crack, comminuted fracture without displacement. depressed fracture.

Symptoms. Local manifestations - a hematoma in the scalp, a wound with an open injury, impressions that are visible or detected by palpation. General signs depend on the degree of brain damage and can manifest as impaired consciousness from a short-term loss of it at the time of injury to deep coma, lesions cranial nerves, respiratory disorders, paralysis. there may be a light gap, then after a few hours again there is a loss of consciousness. The victim may be conscious but not remember the circumstances of the injury and the events preceding the injury (retrograde amnesia). He may be in a state of stupor, stupor, or coma. The more severe the trauma to the skull, the more severe the impairment of consciousness.

The final diagnosis is specified in the hospital or x-ray of the skull.

First aid. If the victim is conscious and in a satisfactory condition, then he is laid on his back on a stretcher without a pillow. An aseptic bandage is applied to the head wound. In the unconscious state of the patient, it is necessary to lay on a stretcher on his back in a half-turn position, for which a roller of outerwear is placed under one side of the body. The head is turned to the side so that in the event of vomiting, the vomit does not enter the respiratory tract, but flows out. To the head - an ice pack. Unfasten all tight clothing. If the victim has dentures or glasses, they are removed. In acute respiratory failure, artificial respiration is performed through a mask. In case of acute respiratory disorders, the victim's mouth is cleaned of vomit, the jaw is moved forward and artificial respiration through the mask is started. With motor excitation, 1 ml of a 1% solution of diphenhydramine or 1 ml of a 2% solution of suprastin is administered intramuscularly as prescribed by a doctor. 2 ml of cordiamine is injected subcutaneously. Narcotic analgesics should not be administered.

Transportation on a stretcher in the supine position. During transport, the possibility of vomiting must be taken into account.

Fracture of the base of the skull often observed when falling from a height on the head, car accidents, domestic injuries.

Symptoms. AT early period bleeding from the ears nose bleed, cerebral symptoms. In more late period there are symptoms of glasses (hemorrhages in the eye sockets), hemorrhage under the sclera and conjunctiva. liquorrhea from the nose and ears, the phenomenon of meningism (stiff neck do not check!).

Diagnosis is based on the presence of the above symptoms and cerebral disorders.

Emergency care: lay the victim horizontally, cold to the head, put an aseptic bandage on the nose and ears (tamponade is undesirable).

Organization of treatment:

1. In the hospital is carried out additional research(radiography, CTG, spinal puncture); surgical treatment (trepanation of the skull)

2. Medical treatment: diuretics, magnesia, antibiotics, antipsychotics, anticonvulsants and symptomatic treatment after consultation with a neurologist. The nasal cavity and ears are instilled with antibiotic solutions.

3. Strict bed rest

4. After discharge, observation by a neuropathologist, complications such as epilepsy, personality changes, hallucinations, etc. are possible, in such cases a psychiatrist's consultation.

Patients with traumatic brain injury need careful care. They need to be rotated periodically, massaged, the toilet of the skin, so that there are no bedsores. In patients with depression of consciousness, impaired swallowing, it is necessary to monitor the condition of the respiratory tract, free the oral cavity from saliva and mucus, carry out the toilet of the oral cavity, eyes, etc.
TBI is one of the most serious injuries that requires special treatment. medical staff to the victim at all stages of treatment, from the scene of the incident to the restoration of working capacity. Features of the provision of first aid and the basic principles of treatment are already outlined in this chapter.

The prognosis for patients with concussion is favorable. With significant brain damage, as a rule, neurological symptoms persist for life with disability (arachnoiditis, hydrocephalus, high blood pressure, vegetovascular dystonia, convulsions, movement disorders and etc.).

Jaw fractures- this is damage to the jawbone with a violation of its integrity.

There are traumatic and pathological fractures (with osteomyelitis, extensive cyst, malignant neoplasm). Fractures can be closed and open when the integrity of the skin or oral mucosa is broken.

The clinical picture is determined by pain, displacement of fragments, their mobility, changes in bite, impaired speech and chewing, and profuse salivation.

Emergency care consists of transport immobilization with a bandage, stopping bleeding, preventing asphyxia and anti-shock measures. Transport immobilization is performed with a rigid chin sling bandage. To prevent asphyxia, the patient is seated or laid on his side.

X-ray allows you to clarify the location and nature of the fracture.

Treatment consists in comparing the fragments and fixing them. Immobilization is provided by wire dental splints, wire or polymer threads, osteosynthesis with metal rods, as well as with the help of special devices (Rudko, Zbarzha) Fig. 7).

Rice. 7 Methods of immobilization of fragments with wire splints for fractures mandible:

a - intermaxillary tying of teeth with a ligature wire (on the left - with the formation of an additional loop according to Ivy, on the right - with direct twisting of the ends of the ligatures); b - single-jaw smooth tire-bracket made of aluminum wire; c - wire splint with a support plane and a spacer bend in the area of ​​missing teeth; g - wire tire with hook loops fastened with rubber rings.

Dislocations of the lower jaw (TMJ). Depending on the direction of displacement of the articular head are divided into anterior and posterior; displacement of the head outward or inward is combined with a fracture of the condylar process.

Dislocations are bilateral and unilateral, acute (from several weeks to several months), habitual (occur repeatedly).

Anterior dislocation can occur with trauma, maximum mouth opening, which most often occurs when yawning, vomiting, biting off a large piece of food, inserting an endotracheal tube, inserting a gastric tube, removing teeth, inserting an impression spoon, opening the mouth with a mouth expander, etc.

Contributing factors can be relaxation of the ligamentous-articular apparatus, a decrease in the height of the articular apparatus, tubercle, a change in the shape of the articular disc, as well as gout, rheumatism, polyarthritis.

Clinically, the dislocation of the TMJ is manifested by a wide open mouth and the inability to close it even with the application of force (in this case, the springy movement of the jaw is determined) and the release of saliva from the mouth, pain in the temporomandibular joints, inability to eat, flattening of the cheeks. X-ray in the lateral projection shows the articular head in an unusual place - anterior to the articular tubercle.

Reduction by the method of Hippocrates. The nurse sits the patient on a chair and gives the doctor a towel. After reduction, a sling-like bandage is applied for 10-12 days or a ligature binding of the teeth of the upper and lower jaws is performed.

Soft tissue wounds in the head and face have their own characteristics . In the CHLO because of the abundance blood vessels profuse bleeding, rapidly growing traumatic edema. Due to the anatomical proximity of large vessels, nerves, organs of vision, hearing, there is a risk of damage to them with subsequent disfigurement of the face and persistent dysfunction of organs, speech and nutrition are difficult. In persons with long hair scalping wounds can be observed if the hair gets caught in the moving parts of any mechanism. In this case, the soft tissues of the head, along with the hair, are completely detached from the skull (scalp).

First aid and treatment. The basis of first aid is the immediate stop of bleeding at the scene. For minor wounds, it is enough to apply a pressure bandage. In case of damage to larger arterial trunks, it is necessary to press the vessel along and deliver the victim to a surgical hospital. When the external temporal artery is injured, it is pressed in front of the auricle, the external maxillary artery - at the lower edge of the lower jaw 1-2 cm anterior to its angle. In the surgical hospital, primary surgical treatment of the wound is performed. Features of wound care in area of ​​the face and head is an economical excision of only obviously non-viable and sharply contaminated wounds with the imposition of primary sutures. Good blood supply promotes smooth healing of wounds.

Medical assistance: PHO wounds, tetanus prevention, antibiotic therapy, pain relief.

Fracture of the cranial vault is a serious injury, which is characterized by a violation of the integrity of the bones of the skull that form it upper part, i.e. the set. In the statistics of injuries, a skull fracture occupies up to 8% of all types of fractures. Such an injury is complex and can cause death of the victim as a result of compression or damage to the brain.

The vault of the skull or its upper part forms several bones of the skull at once. These bones include: parietal, frontal and occipital bones.

The parietal bone is paired and forms a sagittal or sagittal bone suture in the projection of the median line of the body. In front, the vault is formed by the frontal bone, and behind occipital bone. Compound frontal bone with the parietal forms a coronal or frontal bone suture. Compound occipital bone with the parietal forms a lambdoid suture. It is important to note that all the bones of the cranial vault have a spongy structure, that is, they consist of two plates of compact bone substance, and in the middle they have a porous structure.

Causes of the fracture

A calvarium fracture can occur due to many reasons, however, there are only two mechanisms for the formation of a calvarium fracture:

• direct damage. With a similar mechanism, a blow occurs in the head area, as a result of which a section of the bone is pressed into the cranial cavity;
• indirect damage. The place of impact falls on a large area, and damage is detected on the cranial vault.

Most skull fractures occur either as a result of blows to the head with heavy blunt objects large area contact surface, or as a result of a car accident or other road traffic accidents, falls with impacts on a hard object. The mechanism can be any, the main thing is that the strength of the damaging factor is greater than the density of the bone. Fracture of the cranial vault, photo.

Classification

To determine the tactics of managing a patient with a diagnosis of a fracture of the bones of the cranial vault, it is necessary to accurately establish the nature of the fracture.

According to the nature of the fracture, one can distinguish the following types:

• Linear fracture. The bone tissue is damaged in the form of a thin line, roughly speaking, the fracture resembles a crack in the lamellar bone. A linear fracture is one of the most successful options and has minimal risk the development of serious complications, however, there is still a risk of damage to the cerebral arteries adjacent to the inner plate, which may lead to the development of an epidural hematoma of the brain;
• depressed fracture. Occurs as a result of the first mechanism of injury. In this case, the inner plate is deformed and pressed into the substance of the brain. This situation can lead to rupture of the dura mater and trauma to the cerebral cortex and cerebral vessels. A depressed fracture can lead to crushing of the brain substance, the occurrence of massive subdural hematomas with the phenomenon of brain dislocation;
• comminuted fracture. A fracture of the cranial vault of this type is formed at the most strong blows across the cranium. When fractured, it forms a large number of splinters of broken bones. As a rule, fragments have very sharp edges and easily damage the meninges and the brain itself. The consequences of a comminuted fracture are similar to depressed fractures;
• a separate type is a perforated fracture. Damage occurs as a result of the impact of a small object on the bone. An example would be a gunshot fracture or a blow with an object with a pointed end. In this case, a bone defect of various diameters occurs and the substance of the brain and its membranes are almost always damaged.

Skull fracture symptoms

When a fracture of the bones of the cranial vault occurs, a number of syndromes occur that form a characteristic clinical picture. The symptoms of a fracture of the cranial vault include local - local and general - changes in all organs and systems.

To local symptoms can be attributed to a visually determined hematoma or rupture of the skin at the site of direct impact. With significant fractures, the deformation of the cranium is determined. The victim may also be bleeding.

The general cerebral symptoms include a fairly large number of signs that make it possible to judge the severity of the victim's condition. strong headache, which occurs at the time of injury and does not go away when taking analgesics. The victim may be disturbed by nausea and dizziness, in severe cases, vomiting may occur, which does not bring relief. With the most severe fractures of the cranial vault, the patient loses consciousness and may even fall into coma.

When determining vital functions, the victim has uneven pathological breathing, most often of a superficial nature. Arterial pressure can be significantly reduced, the pulse becomes barely perceptible, thready. If the substance of the brain is damaged, paralysis of the motor muscles can occur. The patient's condition directly depends on the presence of hemorrhage and cerebral edema. If edema or hemorrhage occurs, intracranial pressure increases significantly, which can subsequently lead to brain dislocation and inhibition of vital functions, such as cardiovascular and respiratory activity.

Diagnostics

The occurrence of a fracture of the cranial vault does not cause difficulties in diagnosis, however, establishing the severity of the fracture and the presence or absence of serious brain damage is possible only with the help of special diagnostic tests. To confirm the diagnosis of a fracture of the cranial vault, it is necessary to conduct a standard diagnostic complex. The examination begins with the collection of an anamnesis of the disease. It is very important to find out how long ago the injury occurred, since a number of patients develop a condition called a light gap. During the lucid interval, the victim remains stable despite injury, but often a luminous interval is an unfavorable prognostic sign.

The doctor necessarily examines the pupil and checks the reflexes, which helps to conduct a topical diagnosis for lesions various departments central nervous system. Without fail, the victim undergoes an x-ray of the head area in two projections, which helps to confirm the diagnosis of a fracture of the bones of the cranial vault. To clarify the localization of the fragments and draw up an accurate plan surgical intervention diagnosis is supplemented by computed tomography. To determine the extent of damage to the nervous tissue, magnetic resonance imaging and positron emission tomography of the brain are used.

Treatment

Treatment will depend on the type of fracture and the severity of the brain injury. Linear fractures are the easiest to treat. Such an injury is considered closed, i.e., the integrity of the dura mater is not violated, which means that the risk of an infectious process in the nervous tissue of the brain is minimal. For the treatment of a linear fracture of the cranial vault, primary surgical treatment of the wound surfaces of the scalp is used. Then produce hemostasis (stop bleeding) and suturing the wound.

Things are more complicated if the fracture of the cranial vault is depressed or comminuted. Depending on the area of ​​the bone defect, reconstructive surgery may also be required. Plastic surgery using a titanium or polymer implant. In case of injury to the dura mater and significant hemorrhage, they resort to stopping the bleeding, extracting the subdural hematoma and suturing the skin defect of the scalp. The victim must be prescribed concomitant antibiotic therapy to reduce the risk of developing meningitis or encephalitis.

At a fracture closed type with a traumatic brain injury, there is a high probability of developing cerebral hematoma and cerebral edema. Which will inevitably lead to an increase in intracranial pressure and further death. To prevent compression of the brain tissue by edema or hematoma, decompression of the brain is used. The patient is taken to the emergency operating room and decompressed by placing burr holes on the head. Trepanation avoids dislocation of the brain and the development of herniation medulla oblongata into the foramen magnum.

With a perforated fracture or pressure of fragments into the cranial cavity, surgical treatment in the form of decompression trepanation is indicated. It is carried out in the operating room and its essence is to remove fragments and make a hole in the cranial vault, it can be of different diameters. The doctor bites out a section of the bone with special nippers, edematous brain tissues can enter the hole. Later, the defect is closed with a special plate when the threat to life disappears. Such an operation is called decompression trepanation according to Cushing.

Decompression trepanation according to Cushing

In addition to surgical treatment, the victim on the first day is necessarily in the intensive care unit, where all vital signs are monitored. important features until the state of health stabilizes. The respiratory system, saturation, systemic hemodynamics, and blood coagulation are monitored. Be sure to control daily diuresis and water-electrolyte balance, so as not to miss the development of cerebral edema. Powerful antibiotic prophylaxis is carried out to avoid the development of severe infectious processes in the brain, neuroprotective medications.

On average, a patient diagnosed with a calvarium fracture is on inpatient treatment from 15 days to 1.5 months, depending on the severity of the state of health. In severe cases, the victim may remain in a coma for up to several days, while the central nervous system will not begin to adapt to damage.

Effects

With untimely provision of medical care, the consequences of a fracture of the cranial vault can be very deplorable. The most formidable complication is the development of cerebral edema and the wedging of the medulla oblongata into the foramen magnum. In this case, the oppression of the vasomotor and respiratory centers located in it occurs, which inevitably leads to a fatal outcome.

With serious damage to the nervous tissue by fragments, the victim may develop paralysis of the skeletal muscles, which leads to deep disability. In the remote period after the injury, the patient may experience changes in character and behavior. Patients often begin to worry epileptic seizures.

Fractures of the calvarium are divided into several types:

Depressed, in which a broken bone is pressed into the skull. The consequence of this may be damage to the dura mater, blood vessels and medulla, the formation of extensive hematomas;

Comminuted, in which the bone breaks up into several fragments that damage the structures of the brain, and the same consequences appear as with a depressed fracture;

Linear, the least dangerous, in which damage to the cranial bone looks like a thin crack.

With a linear fracture, there is no displacement of the bone plate or it is no more than 1 cm. Bones with this type of fracture can grow together without serious complications and consequences. However, it is possible to form epidural (between the inner surface of the bone and the meninges) hematomas due to internal hemorrhage, which increase gradually and make themselves felt only 1.5-2 weeks after the injury, when the victim is already in a rather serious condition.

Linear fractures account for 80% of skull fractures, especially in children.

In most cases, the parietal bone is damaged, sometimes the frontal and occipital are captured. If the fracture line crosses the lines of the cranial sutures, this indicates a significant force on the head and a high probability of damage to the dura mater. In this regard, such a type of linear fracture is distinguished as diastatic ("gaping"), which is characterized by the transition of the fracture line to one of the cranial sutures (most often found in young children).

Causes of a linear fracture of the skull

Such a fracture, as a rule, appears as a result of an impact with an object with a large area. Usually, there are traces of mechanical impact (abrasion,) above the fracture site.

Skull fractures can be: direct, indirect. With direct impact, the bone is deformed directly at the site of impact, with indirect impact, the impact is transmitted from other damaged bones. Unlike fractures of the base of the skull, fractures of the vault in most cases are straight.

Symptoms of a linear fracture of the skull

A wound or hematoma is found on the scalp, while there is no depression of the bones felt on palpation.

To common features any fracture include:

Lack of pupillary response;

Respiratory and circulatory disorders in case of compression of the brain stem;

Confusion or loss of consciousness.

Craniography is used to make the diagnosis. x-ray examination skull without the use of a contrast agent). In some cases, cracks may extend through several bones. When examining images, special attention should be paid to the intersection of the vascular furrows with a fissure, since this may damage the intracranial vessels and meningeal arteries, which causes the formation of epidural hematomas. Sometimes the edges can be compacted and raised, which creates the impression of a depressed fracture on palpation.

Sometimes in medical practice there are errors when the shadow of the vascular sulcus is taken for an incomplete fracture (crack). Therefore, it is necessary to take into account the location of the arterial grooves and the specifics of their branching. They always branch in a certain direction, their shadows are not as sharp as the fracture lines.

A linear fracture on an x-ray has the following features:

Black fracture line;

The fracture line is straight, narrow, without branching;

Vascular sulcus gray color, wider than the fracture line, sinuous, with branching;

The cranial sutures are gray in color and of considerable width, with a standard course.

8-10 days after TBI, fractures in the bones are more clearly defined than immediately after the injury.

Treatment of a linear fracture of the skull

In the absence of intracranial hematomas and damage to brain structures, linear fractures do not require surgical intervention and require only supportive care, which includes wound treatment and light painkillers. In case of loss of consciousness, the victim is observed in a medical facility for at least 4 hours. If, as a result of an examination by a neurosurgeon, it is found that vital functions are not impaired, the patient can be released under home observation.

Within a few weeks after the injury, the area of ​​the fracture is filled with fibrous tissue. If the fracture line is narrow enough, then its ossification occurs in the future. The ossification process lasts approximately 3-4 months in children and up to 2-3 years in adults. If the width of the crack exceeds a few millimeters, then bone bridges form in the fibrous tissue that fills it.

Conservative treatment is also subject to cracks in the cranial vault, which continue to its base, but do not pass through the walls of the nasal airways, pyramids and cells of the mastoid processes.

The indication for surgical intervention is the displacement of the bone plate, as a result of which it protrudes above the surface of the cranial vault by more than 1 centimeter. In this case, there is a high risk of damage to the meninges and other brain tissues, which can lead to such long-term consequences as epilepsy in the future.

If this fracture occurred in a child under the age of three years and was accompanied by a rupture of the dura mater, then in the future the edges of the fracture line may diverge more widely and a linear defect of the skull is formed. The arachnoid membrane, filled with cerebrospinal fluid, begins to protrude, and the bones gradually diverge even wider. In this case, plastic surgery is recommended.

In most cases, a linear fracture heals without any special consequences for the victim, but, like any other skull fracture, it can provoke development.

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma of educational and scientific medical center Administration of the President of the Russian Federation.

One of the most important and frequently occurring components of TBI in children is skull fractures. Their total frequency reaches 27%, and 2/3 of them are accounted for by closed TBI. Depending on the localization of bone damage, fractures of the vault, base and combined fractures (vault and base) are distinguished. Moreover, the parietal bone is most often damaged, then, in descending order, the frontal, occipital and temporal bones.

Linear, comminuted crushed, comminuted depressed (impression, depression), decompression, perforated (blind, through) fractures and their combinations are distinguished. Of primary importance in children are linear, depressed fractures and fractures of the base of the skull.

Linear vault fractures

Linear fractures of the bones of the cranial vault are characterized by the absence of inward displacement of the internal bone plate and are the most common type of skull injury in children. They occur in approximately 20% of children with TBI and account for 75% of all skull fractures. The parietal bone is most often damaged, often involving the occipital and frontal. The intersection of the cranial suture line with a fracture indicates a significant mechanical impact on the head of the victim and a high risk of damage to the dura mater.

Usually there are traces of mechanical impact above the fracture (abrasions, swelling, hematomas).

The significance of linear fractures of the bones of the cranial vault in children has been the subject of lively discussions for a very long time. Currently, it is believed that a linear fracture in itself does not have a large clinical significance. Its presence indicates only a fairly significant force of mechanical action on the skull at the time of injury, which can cause not only a fracture, but also other, much more dangerous intracranial injuries (brain contusion, rupture of the dura mater, intracranial hemiorrhagia). The possibility of precisely these injuries should be a cause of concern for the clinician and determine the need for additional examination of the child (including visualization of the intracranial state). Of particular importance is a linear fracture of the bones of the cranial vault in infants, since it may be the only sign that allows us to refuse the diagnosis of a minor injury.

If a fracture of the skull bones is suspected and neurological disorders are present, children are shown X-ray of the skull US or CT in tissue and bone modes. In the acute period, a survey x-ray of the skull is usually performed in two projections (frontal and lateral), in severe cases, without changing the position of the child's head, but moving the x-ray tube (Fig. 27-4). If a fracture of the occipital bone is suspected, radiographs are taken in the posterior semi-axial projection, and to exclude or determine the depth of depression - x-rays tangent to the damage site. Sighting images (orbits according to Reza, temporal bones according to Schüller, Mayer, Stanvers) are carried out additionally a few days after the stabilization of the child's condition. It must be remembered that damage to only the outer or inner bone plates is rarely detected on the craniogram. If it is not possible to conduct CT or US, an echo-EG is performed.

The most informative is CT in tissue and bone modes with the study of the integrity of the areas of interest for the vault and base of the skull. For isolated linear skull fractures and minimal neurologic deficits in older children, a lumbar puncture is usually performed to rule out subarachnoid hemorrhage. Regulation on the need for lumbar puncture in children younger age with minimal symptoms is controversial. If a linear fracture is combined with scalp wounds, debridement the latter can be carried out in a dressing room.

A special type of linear fractures are the so-called. "gaping" (diastatic) fractures. They are characterized by the presence of diastasis between the bones of the skull. These fractures may be in the form of a torn suture or through the bone. They are characteristic mainly of infants and the possibility of their occurrence is explained by the incomplete ossification of the skull bones and the fragility of the sutures.

Sometimes, on the 2-5th day after the injury, there is a divergence of the edges of the fracture, in connection with which it is more clearly detected on delayed craniograms. Such fractures in infants most often do not require surgical treatment.

Isolated fractures of the bones of the base of the skull in children under 3 years of age are extremely rare, but the transition of the fracture line from the bones of the vault to the base is observed in 10% of cases. It is necessary to pay special attention to this fact, because. these fractures may have certain consequences in the long-term period of TBI and require timely diagnosis and treatment.

In children older than 3 years, the detection of a gaping fracture is usually accompanied by significant neurological disorders that determine further treatment tactics.

Rice. 27-4. X-ray of the skull in direct (A) and lateral (B) projections. Linear fracture of the frontal and parietal bones on the right (boy 1.5 years old).

Although most intracranial hematomas are not accompanied by linear skull fractures, their combination is very formidable. Most often, linear fractures are combined with epidural and epidural-subperiosteal hematomas, especially when the fracture line crosses the furrows of the middle meningeal artery or venous sinuses. The cause of such hematomas may be the fracture itself (hemorrhage from the area of ​​the damaged bone). With linear fractures of the skull and epidural hematomas, more or less pronounced focal and cerebral symptoms are detected. However, it should be borne in mind that about 5% of children with linear fractures may have "surgically significant" hematomas in terms of volume, which are clinically asymptomatic. That is why children with linear fractures should be included in the risk group for the possibility of developing intracranial hematoma, and all of them need objectivization of the structural intracranial state (CT, US, echo-EG).

A peculiar and rare complication of linear fractures in children are the so-called. "growing fractures" (synonymous with "leptomeningeal cysts"). They occur in cases where, during an injury, not only the bones of the skull are damaged, but also tightly attached to them inner surface dura mater (dura mater). Its damage corresponds to the fracture line. First, the arachnoid membrane bulges into the TM O defect, preventing the healing of this defect. Further, the brain begins to bulge into it, increasing the defect of the dura mater and exerting local pressure on the thin bones of the skull in the area of ​​the fracture. This leads to an increase in bone diastasis in the area of ​​the fracture. Growing fractures occur in less than 1% of children with linear fractures and are predominantly located in the parietal region. More than half of these injuries are observed in children under 1 year old and they are almost not detected in children older than 3 years. X-ray of the skull and US craniography revealed progressive expansion of the fracture. In most cases, such children are subject to surgical treatment, which consists in plastic surgery of the defect in the dura mater and skull, as well as excision of excess soft tissues of the head in the area of ​​the formed bulge. As a plastic material, it is advisable to use a split dura mater (periosteum in infants), and for cranioplasty - the patient's bone material (for example, a split bone or bone chips obtained by applying burr holes, which are used to seal both the fracture area and the burr holes themselves ). In rare cases, there is a bulging of the dilated lateral ventricle into the cavity of the leptomeningeal cyst, which requires preliminary ventriculoperitoneal shunting with a medium-pressure valve system.

A rare complication of a linear fracture of the skull is traumatic aneurysms, which are formed in cases of rupture of the dura and bulging of the arachnoid membrane into its defect with a section of the arterial vessel located in it. Such aneurysms are more common in skull base fractures or depressed fractures.

On the x-ray of the skull, a linear fracture in children under the age of 5 years is detected within 4-8 months, and in older children - on average within 2 years. The prognosis for linear fractures is usually determined by the dynamics of brain damage accompanying the fracture.

Depressed fractures

Depressed fractures occur when an object with a relatively small surface is exposed to the child's skull. On the childhood accounts for about half of all depressed fractures, with a third of them under the age of 5 years. Most often, the parietal and frontal bones are damaged. It is necessary to distinguish between open and closed depressed fractures, as they require different treatment. Open fractures are characterized by the presence of a scalp wound with damage to the aponeurosis above them. Closed fractures include fractures that are not accompanied by damage to the soft tissues of the head, and if there are any, then the aponeurosis remains intact. Closed fractures account for about a third of all depressed fractures and are more common in younger patients. With them, the possibility of developing an intracranial infection is small. Unlike linear fractures, in depressed fractures, the clinic and prognosis are determined not only by intracranial changes accompanying fractures. The characteristics of the fracture itself can significantly affect neurological manifestations injuries and directly determine the treatment tactics. Of primary importance is the localization of the fracture and the depth of depression of the bone fragments. These data can be obtained from x-rays of the skull, and it is often necessary to take additional pictures tangential to the fracture area (Fig. 27-5). The ability to avoid X-ray loading and transportation of the child is provided by US craniography.

Rice. 27-5. X-ray of the skull in the lateral (A) and direct (B) projections. Depressed depression fracture of the frontal bone on the right (8-year-old boy).

The advantage of the US study is the possibility of assessing not only the state of the skull bones, but also the exclusion of intracranial hematomas. Most full information can be obtained with CT, performed in both tissue and bone modes (Fig. 27-6). The issue of surgical treatment of uncomplicated fractures is decided in a planned manner, after the disappearance of the hematoma and edema in the fracture area.

Rice. 27-6. CT-image in the bone mode of a depressed impression fracture of the frontal bone on the right (5-year-old boy).

Convulsions with depressed fractures are more common than with other types of damage to the bones of the skull. 10% of children of all ages with depressed skull fractures experience early seizures (in the first 7 days after TBI) and 15% late seizures (after 7 days). For other types of fractures, these figures reach only 4% and 3%, respectively. More frequent convulsions in depressed fractures are probably associated with damage and/or irritation of the cerebral cortex by bone fragments displaced into the cranial cavity. It is possible to shift into the cranial cavity only the inner bone plate. According to the survey craniograms, these fractures can be erroneously interpreted as linear fractures. Only CT can detect depression.

Indications for surgical treatment of depressed fractures largely depend on the location and depth of the depression, as well as the general condition of the child. According to various authors, impressions with a depth of 5 mm to 10 mm are of surgical importance.

If a child has a wound on his head, after carefully shaving the hair around the wound and treating its edges with antiseptics, the doctor carefully palpates the bone in the area of ​​\u200b\u200bthe edges and bottom of the wound with a gloved finger. If a fracture is detected, then without any additional manipulations, except for hemostasis, the child is given an X-ray of the skull (direct, lateral and tangential images) and Echo-EG (or US). US craniography is ineffective in open depressed fractures. Optimum is CT in bone and tissue modes, which also allows to detect foreign bodies in the cranial cavity (Fig. 27-7).

The main danger of open fractures is infection, so further examination and surgery must be performed quickly. Usually, infectious complications do not exceed 5% if the operation is performed within 48 hours after TBI. Infectious complications are responsible for an increase in neurological disorders, seizures and death.

The stages of surgery for open depressed fractures are as follows: economical excision of crushed wound edges, removal of depressed fragments, inspection of the DM, treatment of brain damage, sealing of the DM, cranioplasty, and wound closure.

If the fracture and wound are located behind the hairy margin, then an S-shaped skin approach can be formed by extending the skin wound. For fractures of the frontal bone, a bicoronal incision is optimal. Identification of a DM defect requires its suturing, and if it is not possible, the defect is repaired with a fragment of the periosteum or a flap formed after stratification of the DM. You should strive to complete the operation with primary autocranioplasty. In most cases, this can be done using bone fragments, fastening them together. Some authors, when bone fragments are contaminated, recommend washing the fragments in an antiseptic solution before their reimplantation. However, it is necessary to rinse the bone fragments well after that to prevent the antiseptic from getting on the membranes of the brain. Of particular importance is the primary reconstruction of the upper edge of the orbit, since there are additional difficulties in its restoration with a delayed crane and plastic surgery.

Conservative treatment is possible if the fracture is located over the venous sinus, since the removal of a bone fragment plugging the sinus rupture can lead to catastrophic bleeding. At the same time, it must be remembered that the localization of fractures over the region of the posterior sections of the superior sagittal sinus, the fusion of the sinuses, the dominant transverse sinus with their compression can lead to the development of a clinical picture of pseudotumorous syndrome. Its main manifestations are increasing symptoms of intracranial hypertension and congested nipples. optic nerves. Therefore, in such cases, it is necessary to objectify the patency of the sinus in the depression area using MR angiography (or cerebral angiography). If objective or clinical signs of impaired blood flow are detected, the operation must be carried out in a planned manner during the first 3 days after the injury. When planning such an intervention, it is necessary to be prepared for abundant hemorrhage. The most appropriate is the implementation of osteoplastic trepanation of the skull with the location of the depressed fragment in the center of the bone flap. During resection trepanation, the bone fragment located above the sinus is removed at the very last moment, after the distal and proximal sections of the sinus are exposed by at least 1 cm. If a damaged area of ​​the sinus is detected, known methods of its plastics are used.

One of the main dangers of open depressed fractures is the possibility of developing intracranial hematomas (intracerebral hematomas are more common). Although they are not common, their presence significantly increases the risk of mortality and disability. For minimal invasiveness during their removal, the most effective is the use of intraoperative US (US navigation and US monitoring at the stages of hematoma removal). If preoperative CT examination is not possible, intraoperative US after removal of bone fragments provides a qualitative assessment of intracranial traumatic changes.

special form depressed fracture - a concave fracture in infants (like a depression in a ping-pong ball). Most often it occurs during childbirth, but it can also occur with trauma to the newborn. There is usually no combination of this type of fracture with intracranial hematomas or any neurological disorders. Since many of these fractures tend to spontaneously reposition, surgical treatment is used in the following cases: 1) severe depression (more than 5 mm); 2) depression-related neurological manifestations or signs of increased intracranial pressure; 3) the presence of CSF in the subgaleal space.

The tactics of surgical intervention for this type of fracture is described in the discussion of birth head injury.

Volume conservative treatment It is determined mainly by concomitant fracture of the brain damage.

Base fractures

The skull of a child is characterized by great plasticity; therefore, fractures of the bones of the base of the skull in children are much less common than in adults. Isolated skull base fractures account for 2.3-5% of all skull fractures and are found mainly in children. school age. Clinical manifestations depend on the location of the fracture. If the bones of the base of the anterior cranial fossa are damaged, periorbital edema, rhinorrhea, anosmia are possible. pyramid fractures temporal bone may be accompanied by hearing loss, paresis of the facial nerve, otorrhea and hemorrhage in the tympanic cavity. Children are characterized by longitudinal fractures of the pyramid, usually resulting from lateral impacts.

The diagnosis of a skull base fracture is most often based on clinical findings. X-ray of the skull is not always effective. Carrying out CT and US in these cases makes it possible to exclude additional injuries, primarily intracranial hematomas. Fractures are not always detected even during CT scan in the bone mode.

The effectiveness of prophylactic antibiotics in these patients has not been proven. The importance of identifying skull base fractures is associated with the risk of complications - CSF fistula followed by recurrent meningitis, as well as damage to the cranial nerves.

Fractures of the base of the anterior cranial fossa in the region of its orbital part represent a particular problem in pediatric neurotraumatology. Isolated fractures of the roof of the orbit in adult patients are very rare, which, unfortunately, cannot be said about young children. Their lack of pneumatized frontal sinus makes the roof of the orbit more vulnerable. In this area, linear or comminuted (without displacement of fragments, with their displacement down or up) fractures can occur. Clinically, they are manifested by periorbital edema, deformity of the upper edge of the orbit, and exophthalmos. The frequent combination of this type of fracture with intracranial injury requires CT. Other types of diagnostics, such as Echo-EG, radiography, US, are not very informative in these cases.

Most orbital roof fractures are treated conservatively. However, with a significant displacement of bone fragments, due to the risk of developing an orbital cerebral hernia, surgical treatment is used. Moreover, when the bone fragments are displaced downward, both intracranial and extracranial (intraorbital) accesses are required. In some cases, it is advisable to use autoplasty of a defect in the bones of the base of the skull with a split fragment of the bones of the cranial vault.

In pediatric neurotraumatology CSF fistulas are a rare but very dangerous complication. They are formed during fractures of the bones of the base of the skull and occur mainly in children over the age of 3 years. The main clinical features include spontaneous CSF leakage from the ear or nose. Usually, liquorrhea appears within the next 1-2 days after the injury. Often there are difficulties in clarifying the nature of the discharge from the nose. Biochemical analysis resolves doubts. In CSF, glucose is two times less than in blood serum and more than in nasal secretions, and there are more chlorides than in serum. by the most simple method, allowing you to quickly distinguish cerebrospinal fluid from a nasal secret is a test with a "handkerchief". After the handkerchief dries in places soaked with nasal secretions, its tissue becomes denser, which is not observed when the handkerchief is soaked with cerebrospinal fluid.

Minor nasal liquorrheas are often very difficult to detect, especially in children who are in a coma. In such cases, the diagnosis becomes apparent when recurrent meningitis occurs, which are the main danger of CSF fistula. The use of antibiotics does not prevent these infectious complications.

After identifying liquorrhea, the child is in bed all the time with a raised head end. With ear liquorrhea, the rotation of the head towards the ear, from which the cerebrospinal fluid flows, is excluded. It is necessary to reduce the risk of episodes accompanied by a temporary rise in intracranial pressure (crying, straining, coughing, psychomotor agitation, convulsions). Often there is a recurrence of liquorrhea after such episodes. Fortunately, the above measures and dehydration therapy in most cases make it possible to achieve the disappearance of liquorrhea within 1-3 days. However, in cases of its continuation for more than 3 days, it is necessary to resort to repeated lumbar punctures. After them, post-puncture holes are formed in the dura mater, through which long-term CSF drainage is carried out extradurally. This helps to close the fistula. If repeated punctures are ineffective, the issue of installing a long-term external (external long-tunnel lumbar drainage) or internal drainage (ventriculoperitoneal shunting with a low-pressure system) is decided.

Inefficiency listed activities dictates the need for a radical intervention with plastic defect of the dura mater and bone. The main condition for the effectiveness of such an operation is to clarify the area of ​​liquorrhea. For this purpose, CT in the bone mode with thin slices is used (frontal image reconstructions are especially effective), radionuclide methods, however, CT cisternography with omnipack is the most effective. There is no significant difference in the frequency of rhino- and otorrhea.

Features of surgical tactics depend on the localization of the liquorrhea area. For damage to the anterior cranial fossa, a bicoronal incision, unilateral craniotomy, and subfrontal intradural access are used. As a plastic material for the dura mater, the periosteum, temporal fascia, or fascia lata of the thigh are used. Seams should be as tight as possible. Some authors recommend the use of medical adhesives (for example, MK-9). AT postoperative period lumbar drainage persists or lumbar punctures continue for several days.

Fractures of the petrous part of the temporal bone, accompanied by otorrhea, are sealed in the same way as the fistulas of the anterior cranial fossa. Access to the area of ​​liquorrhea is determined by the localization of the fistula (in the middle or posterior cranial fossa).

One of the main symptoms of skull base fractures are cranial nerve damage. Fractures of the base of the anterior cranial fossa are characterized by dysfunction olfactory nerve that occurs in about 7 3 children with this type of pathology. Post-traumatic anosmia can last quite a long time (up to 3 or more years). Fortunately, many children tend to regain their sense of smell already within the first 3-4 weeks after injury.

Rare manifestations of head trauma include visual disturbances associated with damage to the optic nerves. They are directly affected by fractures passing through the canals of the optic nerves or the anterior sphenoid processes. In most cases, dysfunction of the optic nerves occurs due to nerve contusion or impaired microcirculation in it. Visual disturbances usually occur immediately after an injury. With delayed visual impairment it is necessary to perform CT scan in the bone mode to assess the lumen of the optic nerve canal. Identification of signs of its narrowing and the growth of visual disturbances may require surgical decompression of the optic nerve.

The oculomotor, trochlear, and abducens nerves are affected mainly at the time of injury, and it is often difficult to distinguish damage to the nerve itself from pathology of the brain stem. These disorders occur with fractures in the region of the superior orbital fissure or, rarely, with oblique and transverse fractures of the clivus.

Trauma to the trigeminal nerve occurs mainly in the region of the supra- and infraorbital openings. Rarely, its damage can be the result of dislocation effects.

Paresis of the facial nerve is often combined with fractures of the petrous part of the temporal bone. In transverse fractures, the nerve is injured in the internal ear canal or the horizontal part of the fallopian canal. Usually there is a sudden dysfunction. Longitudinal fractures can overstretch the nerve, resulting in bruising or compression of the nerve. In acute paralysis of the facial nerve and the absence of signs of restoration of its functions, some authors consider it expedient to decompress it 3 weeks after the injury. The inefficiency of decompression requires a solution to the issue of facial nerve plasty. With delayed paresis of the facial nerve, immediate decompression is necessary. Transverse fractures of the petrous temporal bone may present with auditory (hypoacusia, tinnitus) and/or vestibular disorders.

It is extremely rare for primary traumatic injuries of the caudal group of nerves to occur. Usually they are combined with fractures of the base of the skull, passing through the jugular foramen.

A.A. Artaryan, A.S. Iova, Yu.A. Garmashov, A.V. banin