Basilar Skull Fx Pic 2013 12

8/12/2019 Basilar Skull Fx Pic 2013 12

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Incidence- overall

Anatomy- Each section

Evaluation

Management

Objectives


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No drugs will cure skull base fractures.

I do not own stock in medical equipment.

However, I do drive a car, own a baseball bat andwork at the TDC hospital.

Disclosure for CME


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In US, 2 million head injuries occur yearly.

Leading cause of death and disability of children.

Motor vehicle accidents are leading cause of headtrauma in industrialized countries.

Up to 1/3 of motor vehicle injuries involve head and

neck injuries and 28% of all fractures of involving MVAare of the head and neck region.

Incidence

cElhaney JH, Hopper RH Jr, Nightingale RW, Myers BS. Mechanisms of basilar skull fracture. J Neurotrauma. 1995 Aug;12(4):669-78. PubMed PMID: 8683618.


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Skull base fractures occur in 3.5-24 % of head injuries.

Traumatic Coma Data Bank states 25% of severe headinjuries

Incidence

Eisenberg, Howard M., et al. "Initial CT findings in 753 patients with severe head injury: a report from the NIH Traumatic Coma Data Bank.

Journal of neurosurgery 73.5 (1990): 688-698.

http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/

They account for2% of all traumas


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Behbahani 2013- Retrospective study 1606 pt. inTuscon.

Incidence


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Skull base fracture incidence is increased with orbitalwall/rim fractures (36%) and ZMC Fractures (29.9%).

Infrequent with nasal bone (7.7%) and mandible fractures(4.0%).

The incidence of skull base fracture was directly associatedwith the number of facial fractures per patient; one facialfracture (21.0%), two facial fractures (30.4%), and three ormore facial fractures (33.3%).

Temporal bone fractures are associated 18-40% of the time.

Frontal sinus fractures occur 15-20% of the time.

Incidence with other fracture(s)

Slupchynskyj, O. S., Berkower, A. S., Byrne, D. W. and Cayten, C. G. (1992), Association of skull base and facial fractures. The Laryngoscope, 102: 12471250Temporal bone fracture: evaluation and management in the modern era. Johnson F - Otolaryngol Clin North Am - 01-JUN-2008; 41(3): 597-618Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical management and complications. J Craniomaxillofac Surg.2000;28:133139.


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Anatomy

Examination of the skull and brain: method of removing the brain after it is severed from the bodyHenry W. Cattell, 1903


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Anatomy


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Anatomy

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=&showPage=diagnosis&contentUrl=/srg/93/01-Diagnosis/skull_base-skull_base.jsp
https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIhttps://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjI


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Anatomy

https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=&showPage=diagnosis&contentUrl=/srg/93/01-Diagnosis/skull_base-skull_base.jsp
https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjIhttps://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjI


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Anatomy

Base of skull: above, 2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License. Accessed on [12-11-2013].


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Anatomy


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Anatomy



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Anatomy


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Anatomy



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Anatomy: Fractures


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Anatomy: Fractures


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Anatomy: Fractures


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Anatomy: Fractures

RK Jackler Atlas of Skull Base Surgery and Neurotology 2009


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This includes posterior frontal sinus, roof of ethmoid,cribriform and orbital roof.

Classification (Damianos):

Type 1- Cribriform fractures- linear through cribriform.

Type 2- Frontoethmoid fracture- Ethmoids and medialfrontal sinus walls.

Type 3- Lateral frontal fracture- Through the lateral

frontal sinus to the superomedial wall of orbit. Type 4- Mixed- any combination of above.

Anatomy: Anterior Skull BaseFractures

Damianos SA, David BJ, Ameen AA, et al. Compound anterior cranial base fractures: classification using computerized tomographyscanning as a basis for selection of patients for dural repair. J Neurosurg 1998;88:471-477


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Anatomy: Anterior Skull BaseFracturesType I Fractures



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Type II fractures



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Type III fractures



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Anatomy: Middle Skull Base


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Anatomy: Middle Skull Base:Temporal Bone


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Collins JM, Krishnamoorthy AK, Kubal WS, Johnson MH, Poon CS. Multidetector CTof temporal bone fractures. Semin Ultrasound CT MR. 2012 Oct;33(5):418-31


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Collins JM, Krishnamoorthy AK, Kubal WS, Johnson MH, Poon CS. Multidetector CTof temporal bone fractures. Semin Ultrasound CT MR. 2012 Oct;33(5):418-31


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2011-Kang-Seoul 128 patients 2003-2010.

Hearing loss noted 78 pt. 9 otic violating- with 8 (88.9%) having SNHL.

68 otic sparing- with 18 (26.1%) having SNHL.


Kang HM, Kim MG, Boo SH, Kim KH, Yeo EK, Lee SK, Yeo SG. Comparison of theclinical relevance of traditional and new classification systems of temporal bonefractures. Eur Arch Otorhinolaryngol. 2012 Aug;269(8):1893-9


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Little and Kesser 2006- Showed 5 fold increase in facial nerve

injury, 25 fold increase in SNHL and 8 fold increase in CSF leakswith otic capsule violating fractures.

They also showed a correlation among OCV fracture and facialnerve paresis or paralysis, In a large series of 820 temporal bonefractures facial nerve paralysis occurred in 48% of OCV fractures

versus only 6% in OCS fractures. The incidence of otic capsule violating fracture is 2.5% to 5.6%.



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Uncommon, 9/25000 (0.39%) recorded in one case

series over 5 years. All patients had cranial nerve defects (II, III, IV, V, VI,

VII, VII), with VI and VII most common (66%).

Longitudinal fractures have worse prognosis, with 3

out of 5 patients died from verebrobasilar injury. Transverse had 1 out of 4 die from carotid artery

injury.

Posterior Fossa: Clivus fractures

Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194198DOI 10.1007/s10143-004-0320-


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Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194198

DOI 10.1007/s10143-004-0320-2


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Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194198

DOI 10.1007/s10143-004-0320-2


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High energy blunt trauma with compression,

rotational or lateral bending injuries to head. Type I- Axial compression with comminution of

occipital condyle-stable injury with no displacement.

Type II- Direct blow that occurs with skull base and

occipital condyle- intact alar ligaments. Type III- Avulsion with lateral or rotational forces with

torn alar ligaments and fractures.

Posterior Fossa: Occipitalcondylar fracture


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Evaluation

http://www.missmassacre.net/?p=2460


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Periorbital ecchymosis (raccoon eyes) Conjunctival hemorrhage Anosmia

Mastoid ecchymosis (Battles sign) Vision changes CSF rhinorrhea or otorrhea Step off of supraorbital ridge Hearing loss

Facial paralysis Facial numbness

Physical Exam


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Frontal bone fractures had the most clinical signs.

Battles sign (100%) and unilateral Periorbitalecchymosis (90%), bloody otorrhea (70%) are highestpredictive value for skull base fracture.

Patients with GCS of 13-15, PPV for intracranial lesionswas (78%) periorbital ecchymosis, (66%) Battles signand (41%) bloody otorrhea.

Clinical signs

Positive predictive values of selected clinical signs associated with skull base fractures. (PMID:11105835)

Pretto Flores L, De Almeida CS, Casulari LAJournal of Neurosurgical Sciences [2000, 44(2):77-82; discussion 82-3]
http://europepmc.org/abstract/MED/11105835?europe_pmc_clipboard_abs_redirect=/abstract/MED/11105835http://europepmc.org/abstract/MED/11105835?europe_pmc_clipboard_abs_redirect=/abstract/MED/11105835


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Periorbital Ecchymosis

http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.html


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Battle sign - Think Basilar Skull Fracture

Battle sign

http://www.dooey.net/OMFS/


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CSF Rhinorrhea

http://amandela.sg/a-runny-nose-may-not-just-be-a-runny-nose/


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Eighty percent of cerebrospinal fluid (CSF) leaks occur

following nonsurgical trauma (16% surgical). Occur in 2% of all head traumas, and 12% to 30% of all

basilar skull fractures, M>F.

50% appear in first 2 days, 70% in one week, and

almost all seen in 3 months.

CSF Rhinorrhea


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CSF Rhinorrhea

REtRoSPECtivE StuDY oF SKuLL BASE FRACtuRE: A StuDY oF iNCiDENtS, ComPLiCAtioNS, mANAgEmENt, ANDoutComE ovERviEW FRom tRAumA-oNE-LEvEL iNStitutE ovER FivE YEARS Michael lemole, Md, Mandana Behbahani,

Ba (presenter), university of arizona college of Medicine


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Cranial nerve injuries

https://reader010.{domain}/reader010/html5/0618/5b275dd42fdc6/5b275de852390.jpg


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CN I- anosmia- from anterior fossa injuries(cribriform). Sense of smell may return over severalmonths. Workup is limited with CT scan.

CN II- Blindness worst outcome- from damage tothe optic canal or orbit. Sphenoid body with sellaturcica damage can cause injury to the optic

chiasm, causing bitemporal blindness.

Cranial nerve injuries: AnteriorCranial Fossa

Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New York:Elsevier; 1976:2757.Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756764.


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CN IV- diplopia-

Least common injury site. Cause from stretching ofnerve as it exits from the dorsal midbrain.

Treatment same as CN III, with patch andspontaneous recovery.

CN V- Sensory deficits to the face. V1-supraorbital, V2-maxillary, V3-mandibular.

V1 most commonly damaged portion, with injury atsupraorbital notch.

Cranial nerve injuries: MiddleCranial Fossa


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CN VI- diplopia. Damage to the clivus. Also stretchedor avulsed when leaving the pons. Unable to abduct.Conservative treatment with spontaneous recovery.

Superior orbital fissure fractures can damage CN III, IV,VI and V1- known as superior orbital fissure syndrome.When accompanied by blindness, it is known as orbitalapex syndrome and involves optic foramen.




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CN VII- facial paralysis. Most common temporal bone,50% of transverse and 25% of longitudinal fractures asinjuries. ENoG of 90% denervation should undergo

surgery. CN VIII- Hearing loss, vestibular damage. Cochlear

and vestibular nerve damage, or damage to oticcapsule can lead to total degeneration with deafness

and labyrinthine dysfunction. Workup withAudiogram, ABR, and ENG. Cochlear implants have84% success rate of return to speech understanding.



l


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CN IX, X, XI- exit out of jugular foramen and CN XII exit outof hypoglossal foramen.

Glossopharyngeal injury leads to dysphagia and loss of gag

Vagus nerve results in ipsilateral cord or palate weaknesswith hoarseness.

Spinal accessory nerve causes weakness with headrotation and shoulder elevation. Hypoglossal nerve injury

causes atrophy of ipsilateral tongue. Treatment is usually supportive with therapy.

Cranial nerve injuries: PosteriorCranial Fossa



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X-Ray skull: Not recommended; delays diagnosis of

intracranial injury. It is not recommended for most head traumas. It has

some benefit for non accidental trauma in children.

Evaluation: Imaging

hornbury JR, Masters SJ, Campbell JA. Imaging recommendations for head trauma: a new comprehensive strategy.AJR Am J Roentgenol. Oct 1987;149(4):781-3


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HRCT scan is the gold standard for skull base injury. It

has the best modality to evaluate bony fractures. The slices should be 1-1.5 mm thick at the most.

Helical CT scans are useful in the evaluation ofoccipital condylar fractures.

CT Angiography is an excellent, quick, non-invasivetechnique for the assessment of cerebral vasculature.

Evaluation: Imaging: CT


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Evaluation: Imaging: CT

htt : www.a ee ournals.com eJournals ShowText.as x?ID= 0 &T e=FREE&TYP=TOP&IN= eJournals ima es JPLOGO. if&IID=2 8&isPDF=NO


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Imaging: CT


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Imaging: CT

Textbook of Head Injury Raj Kumar, A. K. Mahapatra JP Medical Ltd, 2012 - Medical- 320 pages
http://www.google.com/search?tbo=p&tbm=bks&q=subject:%22Medical%22&source=gbs_ge_summary_r&cad=0http://www.google.com/search?tbo=p&tbm=bks&q=subject:%22Medical%22&source=gbs_ge_summary_r&cad=0


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Imaging: CT

Multidetector CT of Temporal Bone Fractures John M. Collins, Aswin K. Krishnamoorthy, Wayne S. Kubal, Michele H. Johnson, Colin S. Poon Seminars in ultrasound, CT, and MR 1 October 2012 (volume 33 issue 5 Pages 418-431


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Imaging: CT



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Imaging: CT



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Approximately 50% of patients with skull base fracturespresent with delayed ischemic brain damage. Carotidinjuries include carotid disruption, compression byfracture fragments or associated hematoma, arterial

wall contusion or hematoma, arterial dissection, carotidcavernous fistula, and occlusion.

Behbahani 2013- Retrospective study 1606 pt. in Tuscan,16 patients had fractures extending to carotid canal, but

no carotid injures noted on angiographic studies.

Evaluation: Vascular injuries

Samii M, Tatagiba M. Skull base trauma: diagnosis and management. Neurol Res 2002;24:147-156


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Biffl et all (1999)

A total of 249 patients underwent arteriography; 85(34%) had injuries.

Independent predictors of carotid arterial injury were:Glasgow coma score 6, petrous bone fracture,diffuse axonal brain injury, and LeFort II or III fracture.Having one of these factors in the setting of a high-risk mechanism was associated with 41% risk of injury.


Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Elliott JP, Burch JM.Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999


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Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. RadioGraphics2008;28(6):16891708; discussion 17091710


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Provides greater soft tissue detail but less bony detailcompared to CT.

FSE T-1 or T-2 with post contrast enhancement are

preferred methods to evaluate skull base. T-2 fat suppression with image reversal is used to

highlight CSF.

T2 weighted thin sliced images (FIESTA) is used to

evaluate cranial nerves.

Imaging: MRI

Skull Base, Orbits, Temporal Bone, and Cranial Nerves: Anatomy on MRImaging Magn Reson Imaging Clin N Am 19 (2011) 439456doi:10.1016/j.mric.2011.05.006


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Imaging: MRI

Evaluation: CSF


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CSF evaluation

Halo or Ring Sign

Bloody CSF placed on a piece of filter paper Blood will separate out from the CSF (central blood

with clear ring).

The ring sign is not specific to bloody CSF

Blood mixed with water, saline, and other mucus willalso produce a ring sign.

Evaluation: CSFRhinorrhea/Otorrhea

Dula, DJ, MD and Fales, F, MD. The 'Ring Sign': Is It a Reliable Indicator for Cerebral Spinal Fluid?Annals of Emergency Medicine, 1993;22:718-720


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Evaluation: CSF


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Beta-2-transferrin

Protein produced by enzymes only in CNS.

Test requires 0.5cc of fluid.

Highly sensitive and specific for CSF.

Beta-trace protein

Found in CSF, heart, and serum.

Not routinely ordered as it may be altered in many cases.

Elevated with renal insufficiency, multiple sclerosis,cerebral infarctions, and some CNS tumors.

Evaluation: CSFRhinorrhea/Otorrhea

Moyer, P. Beta-Trace Protein Shows Promise as a Marker for Diagnosing CSF Leaks. Doctors Guide. Online[Available]:

http://www.docguide.com/dg.nsf/PrintPrint/5DF097A1EB04B3FA85256C3E00731E65, 2002


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Useful in detection of CSF leaks.

Involve intrathecal administration of radiopaquecontrast (metrizamide, iohexol, or iopamido)

followed by CT scan. Up to 80% sensitivity.

However results vary with intermittent leaks, andcontrast may obscure visualization of leak site.

Imaging: CT cisternograms

Meco C, Oberascher G, Arrer E, et al. Beta-trace protein test: new guidelines for the reliable diagnosis ofcerebrospinal fluid fistula. Otolaryngol Head Neck Surg 2003;129:50817


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CSF Rhinorrhea


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CSF Rhinorrhea

http://www.chatrath.com/featuredcases.html


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CSF Rhinorrhea


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Treatment begins with conservative management ofstrict bed rest, HOB >30 degrees, no cough, sneezing,straining.

Currently, after two separate meta-analysis showed

conflicting data, a Cochrane review was done forevaluation of prophylactic antibiotics for CSF leaks.

The analysis concluded that the evidence does notsupport the use of prophylactic antibiotics to reduce

the risk of meningitis in patients with basilar skullfractures or basilar skull fractures with active CSFleak.

CSF Rhinorrhea

Ratilal BO, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilarskull fractures. Cochrane Database Syst Rev 2006;(1): CD004884.


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Conservative management for 7 days has resolutionsrate of 85%.

Continued leakage is then treated with lumbar

drainage of 10 ml/hr. This increases resolution rate to90%.

Therefore, surgical intervention is reserved forpatients who do not resolve with the above

measures.

CSF Rhinorrhea

Bell RB, Dierks EJ, Homer L, et al. Management of cerebrospinal fluid leak associatedwith craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62(6):67684.


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Skull base injuries offer complex fractures that

require thorough evaluations. Division in 3 cranial vaults provides a reasonable way

for evaluation.

Radiographic evaluation is important, along with

history and physical exam. Treatment measure typically begin with conservative

treatment, with surgical intervention saved for severeor persistent disease.

Conclusion


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Slupchynskyj, O. S., Berkower, A. S., Byrne, D. W. and Cayten, C. G. (1992), Association of skull base and facial fractures.The Laryngoscope, 102: 12471250

Eisenberg, Howard M., et al. "Initial CT findings in 753 patients with severe head injury: a report from the NIHTraumatic Coma Data Bank."Journal of neurosurgery73.5 (1990): 688-698.

http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/ Positive predictive values of selected clinical signs associated with skull base fractures. (PMID:11105835) Pretto Flores L, De Almeida CS, Casulari LA

Journal of Neurosurgical Sciences [2000, 44(2):77-82; discussion 82-3] http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.html https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMD

A08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=&showPage=diagnosis&contentUrl=/srg/93/01-Diagnosis/skull_base-skull_base.jsp

Textbook of Head Injury Raj Kumar, A. K. Mahapatra JP Medical Ltd, 2012 - Medical- 320 pages Driscoll CL, Lane JI. Advances in skull base imaging. Otolaryngol Clin North Am. 2007 Jun;40(3) cElhaney JH, Hopper RH Jr, Nightingale RW, Myers BS. Mechanisms of basilar skull fracture. J Neurotrauma. 1995

Aug;12(4):669-78. PubMed PMID: 8683618.:439-54, vii. Review. PubMed PMID: 17544690. http://www.lhsc.on.ca/Health_Professionals/CCTC/edubriefs/baseskull.htm Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New

York: Elsevier; 1976:2757. Base of skull: above, 2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License.

Accessed on [12-11-2013]. Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756764.

References
http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://europepmc.org/abstract/MED/11105835?europe_pmc_clipboard_abs_redirect=/abstract/MED/11105835http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.htmlhttp://www.google.com/search?tbo=p&tbm=bks&q=subject:%22Medical%22&source=gbs_ge_summary_r&cad=0http://www.lhsc.on.ca/Health_Professionals/CCTC/edubriefs/baseskull.htmhttp://www.lhsc.on.ca/Health_Professionals/CCTC/edubriefs/baseskull.htmhttp://www.google.com/search?tbo=p&tbm=bks&q=subject:%22Medical%22&source=gbs_ge_summary_r&cad=0http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.htmlhttp://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.htmlhttp://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.htmlhttp://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.htmlhttp://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.htmlhttp://europepmc.org/abstract/MED/11105835?europe_pmc_clipboard_abs_redirect=/abstract/MED/11105835http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/


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Basilar Skull Fx Pic 2013 12