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Basilar fracture management

MEDICAL THERAPY 

 Adults with simple linear fractures who are neurologically intact do not require any intervention andmay even be discharged home safely and asked to return if symptomatic. Infants with simple linear fractures should be admitted for overnight observation regardless of neurological status.

Neurologically intact patients with linear basilar fractures also are treated conservatively, withoutantibiotics. Temporal bone fractures are managed conservatively, at least initially, because tympanicmembrane rupture usually heals on its own.

imple depressed fractures in neurologically intact infants are treated e!pectantly. These depressedfractures heal well and smooth out with time, without elevation. ei"ure medications arerecommended if the chance of developing sei"ures is higher than #$%. &pen fractures, if contaminated, may require antibiotics in addition to tetanus to!oid. ulfiso!a"ole is a commonrecommendation.

Types I and II occipital condylar fractures are treated conservatively with neck stabili"ation, which isachieved with a hard '(hiladelphia) collar or halo traction.

SURGICAL THERAPY 

The role of surgery is limited in the management of skull fractures. Infants and children with opendepressed fractures require surgical intervention. *ost surgeons prefer to elevate depressed skullfractures if the depressed segment is more than + mm below the inner table of adacent bone.Indications for immediate elevation are gross contamination, dural tear with pneumocephalus, and anunderlying hematoma. At times, craniectomy is performed if the underlying brain is damaged andswollen. In these instances, cranioplasty is required at a later date. Another indication for earlysurgical intervention is an unstable occipital condylar fracture 'type III) that requires atlantoa!ialarthrodesis. This can be achieved with inside-outside fi!ation. #/0

In a retrospective study by Bonfield et al, the maority of pediatric skull fractures were found to bemanaged conservatively, and of those requiring surgical intervention, fewer than half of the surgerieswere performed solely for skull fracture repair only. urgical intervention was more likely in patientswho were hit in the head with an obect or were involved in a motor vehicle crash. 1rontal bonefractures were more likely to necessitate repair, and those patients treated for traumatic brain inuryhad a greater incidence of # or 2 bones involved in the fracture. *ost of the complications thatoccurred were related to the underlying trauma, not the surgery. In addition, none of the patients whounderwent intervention for repair of only skull fracture had a worsening of neurologic status. ##0

3elayed surgical intervention is required in ossicular incongruences resulting from a longitudinal skullbase fracture of the temporal bone. &ssiculoplasty may be needed if hearing loss persists for longer than 2 months or if the tympanic membrane has not healed on its own. Another indication is persistent41 leak after a skull base fracture. This requires precise detection of the site of leak before anysurgical intervention is instituted.

PREOPERATIVE DETAILS 

Blind probing of skull wounds should be avoided. (atients are prepared for surgery, and e!ploration is

performed in the operating suite under direct vision to prevent loose pieces of bone from damaging

the underlying brain. (atients with open contaminated wounds are treated with tetanus to!oid and

broad-spectrum antibiotics, especially in a delayed presentation.

INTRAOPERATIVE DETAILS 

Overview

To maintain intracranial pressure, mannitol '/ g5kg) may be given at the beginning, and the(a&# should be kept at 2$-2+ mm 6g during the surgery. (atients should be secured firmly to thetable, allowing Trendelenburg or reverse Trendelenburg positioning if required. A la"y 77 or a

horseshoe-shaped incision is made over the depression. A bicoronal incision is preferred for foreheaddepressions.

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Bony fragments are elevated, and the dura is inspected for any tears. If a dural tear is found, it shouldbe repaired. pecial attention is given to hemostasis to prevent postoperative epidural collection.Bony fragments are soaked in antibiotic5isotonic sodium chloride solution and are reassembled.8arger pieces may be wired together. Alternatively, titanium mesh also may be used to cover thedefect. *ethyl methacrylate can be used instead of the bone pieces, but this should be avoided inchildren. Indeed, absorbable bone plates and screws are recommended for use in children.

Venous sinus tears

3epressed fracture over a venous sinus poses a unique situation requiring special attention. Thedecision to operate is based on the neurological status of the patient, the e!act location of the sinusinvolved, and the degree of venous flow compromise. A preoperative angiogram with venous flowphase or magnetic resonance angiography is recommended whenever a depressed fracture isthought to be over a venous sinus. 9seful data regarding the position and e!tent of occlusion andtransverse sinus dominance is obtained that can affect decisions regarding surgery.

 A neurologically stable patient with a closed depressed fracture over a venous sinus should beobserved. A patient with an open depressed fracture over a patent venous sinus who is neurologicallystable should undergo skin debridement without elevation of the fracture, but if the patient isneurologically unstable, urgent elevation of the depressed fragment is required. &n the other hand, if 

the patient is neurologically stable and the sinus is thrombosed, it can be assumed that ligation of thesinus can be tolerated.

9sually, the anterior one third of the superior sagittal sinus can be ligated without any consequences:however, tears in the posterior two thirds need repair, either primarily or with a galea or pericraniumpatch. Alternatively, a piece of muscle or ;elfoam may be sutured over the sinus.

pecial surgical techniques are used when a skull fracture communicates with mastoid or frontal air sinuses. The communication of the intracranial space with the outside world needs to be eliminated. #20

POSTOPERATIVE  DETAILS 

&ther than the usual immediate postoperative care, the risk of intracranial hematoma and venoussinus thrombosis should be kept in mind in contaminated depressed fractures.

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 Adults with simple linear fractures of the vault, without any loss of consciousness at the time of initialpresentation and with no other complications, do not require long-term follow-up. &n the other hand,infants with similar fractures with dural tears need to be monitored more closely because of thepossibility of the skull fracture e!panding.

(atients with contaminated open depressed skull fractures treated surgically should be monitored withrepeat 4T scans a few times over the ne!t #-2 months to check for abscess formation. 1ollow-up alsois dictated by the complications associated with skull fractures, for e!ample, sei"ures, infections, andremoval of bone pieces at the time of initial debridement.

COMPLICATIONS 

1ailure to recogni"e skull fracture has more consequences than the complications resulting fromtreatment. The chance of a concomitant cervical spine inury is /+%, and this should be kept in mindwhen assessing a patient with skull fracture.

Linear skull fracture

In infants and children, a simple linear fracture, if associated with a dural tear, can lead tosubepicranial hygroma or a growing skull fracture 'leptomeningeal cyst). This may take up to =months to develop, resulting from the brain pulsating against a dural defect that is larger than thebone defect. >epair of such a defect is performed using a split-thickness bone graft. ;rowing skullfracture has also been reported in literature following a stab wound to a gravid abdomen in the lasttrimester .#?0

 A fracture line crossing over a vascular groove, such as the middle meningeal artery, may form anepidural hematoma.#+0 imilarly, a fracture line that crosses over a suture may cause sutural diastasis.

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Basilar skull fracture

The risk of  infection is not high, even without routine antibiotics, especially with 41 rhinorrhea. 1acialpalsy and ossicular chain disruption associated with basilar fractures are discussed in the 4linicalsection. 6owever, notably, facial palsy that starts with a #- to 2-day delay is secondary to neurapra!iaof the @II cranial nerve and is responsive to steroids, with a good prognosis. A complete and sudden

onset of facial palsy at the time of fracture usually is secondary to nerve transection, with a poor prognosis.

&ther cranial nerves also may be involved in basilar fractures. 1racture of the tip of the petroustemporal bone may involve the gasserian ganglion. An isolated @I cranial nerve inury is not a directresult of fracture, but it may be affected secondarily because of tension on the nerve. 8ower cranialnerves 'I, , I, and II) may be involved in occipital condylar fractures, as described earlier in@ernet and 4ollet-icard syndromes 'vide supra). phenoid bone fracture may affect the III, I@, and @Icranial nerves and also may disrupt the internal carotid artery and potentially result inpseudoaneurysm formation and caroticocavernous fistula 'if it involves venous structures). 4arotidinury is suspected in cases in which the fracture runs through the carotid canal: in these instances,4T-angiography is recommended.

Depressed skull fracture

In addition to the risk of infection in contaminated depressed skull fractures, a risk of developingsei"ures also e!ists. The overall risk of sei"ures is low but is higher if the patient loses consciousnessfor longer than # hours, if an associated dural tear is present, and if the sei"ures start in the first weekof inury.