The slides are a presentation for my externship course (neurosurgery) to discuss about skull fractures. It conclude epidemiology, anatomy, mechanism, evaluation, diagnosis, types, and management. All are based on UpToDate.

1. Skull Fractures in adults
Zainab Shafiezade
Bahman 98
Mustafa Khomaini Hospital
‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. INTRODUCTION

3. EPIDEMIOLOGY
 Most frequently fractures ( parietal -> the temporal, occipital, and frontal
bones)
 Traumatic brain injury (TBI)
 most common causes of head injury
• Falls
• Assaults
• Motor vehicle collisions
• Penetrating missiles
 Certain skull fracture types are associated with significant morbidity and
mortality
• depressed skull fractures, basilar skull fractures with associated cerebral spinal
fluid (CSF) leak, and fractures of the temporal-parietal bone that traverse the
middle meningeal artery and vein

4. ANATOMY AND MECHANISM OF INJURY

5. ANATOMY AND MECHANISM OF INJURY

6. ANATOMY AND MECHANISM OF INJURY
 Layers, Thickness
 High risk fractures
 Kinetic energy

7. PREHOSPITAL MANAGEMENT
 Immobilization
 Steady direct pressure at the source of bleeding
 Circumferential head bandage (insuf

8. INITIAL EVALUATION
 Rapid identification and stabilization of life-threatening injuries
 Airway protection
 Direct pressure
 Raney Clips
 Large sutures
 Quikclot , ...
 2ndary survay
 Radiography

9. DIAGNOSTIC IMAGING
 Noncontrast computed tomography
 Bone window
 Tissue window
o Multidetector computed tomography (MDCT)
The axial image of the skull in the transverse plane using bone windows (A) is
displayed alongside the 3D reconstructed view (B). A linear fracture of the right
occipital bone (arrow) is noted just to the right of midline. The 3D view shows the
fracture extending from the right side of the lambdoid suture to the inferior
margin of the right occipital bone

10. DIAGNOSTIC IMAGING
 Magnetic resonance imaging (MRI)
o vascular or ligamentous injury

11. DIAGNOSTIC IMAGING
 CT angiography or other types of angiography

12. DIAGNOSTIC IMAGING
 Skull radiographs
 Plain vs. Tangential views
The plain films of the skull in the AP
Towne's view (A) and lateral view (B)
reveal a linear fracture of the right
occipital bone (arrows A). The lateral
view shows the fracture involving the
parietal bone as well (arrows B).

13. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Linear skull fracture

14. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Depressed skull fracture
CT scan showing a depressed skull
fracture in the right frontal region
(arrows).

15. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Depressed skull fracture
Depressed skull fracture with
intracerebral hemorrhage.
(A) Lateral radiograph shows a
comminuted depressed fracture in
the parietal region (arrows).
(B) CT image using bone windows
shows the depressed fragment
(arrow).
(C) Same image using brain windows
shows multiple areas of intracranial
hemorrhage (arrows) adjacent to
the fracture.

16. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Basilar skull fracture
Skull fracture in the left temporal
region with epidural hematoma. CT
image using brain windows shows
the lentiform epidural hematoma (*)
in the left frontal region. Notice the
superficial hematoma and gas in the
left temporal region (arrow) and
compression of the left lateral
ventricle

17. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Basilar skull fracture
The same skull fracture in
the left temporal region
seen with bone windows in
a slightly more caudad
slice (arrow).

18. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Basilar skull fracture

19. DEFINITION AND PRESENTATION OF
SKULL FRACTURE TYPES
 Basilar skull fracture
 traumatic carotid cavernous fistula (TCCF)

20. FRACTURE TYPESDEFINITION AND
PRESENTATION OF SKULL
 Penetrating skull fracture

21. MANAGEMENT OF SPECIFIC INJURIES
 Linear fractures

22. MANAGEMENT OF SPECIFIC INJURIES
 Depressed fractures
 Tetanus status
 prophylactic antibiotics
 Anticonvulsants

23. MANAGEMENT OF SPECIFIC INJURIES
 Basilar fractures

24. MANAGEMENT OF SPECIFIC INJURIES
 Anticoagulated patients

25.  Penetrating injuries
 Recommended intravenous
dosages of antimicrobial
therapy for adults with
bacterial meningitis who
have normal renal and
hepatic function
Antimicrobial agent Dose (adult)
Amikacin 5 mg/kg every 8 hours*
Ampicillin 2 g every 4 hours
Aztreonam 2 g every 6 to 8 hours
Cefepime 2 g every 8 hours
Cefotaxime 2 g every 4 to 6 hours
Ceftazidime 2 g every 8 hours
Ceftriaxone 2 g every 12 hours
Chloramphenicol 1 to 1.5 g every 6 hours
¶
Ciprofloxacin 400 mg every 8 to 12 hours
Gentamicin 1.7 mg/kg every 8 hours*
Meropenem 2 g every 8 hours
Moxifloxacin 400 mg every 24 hours
Δ
Nafcillin 2 g IV every 4 hours
Oxacillin 2 g IV every 4 hours
Penicillin G potassium 4 million units every 4 hours
Rifampin 600 mg every 24 hours
◊
Tobramycin 1.7 mg/kg every 8 hours*
Trimethoprim-sulfamethoxazole
(cotrimoxazole)
5 mg/kg every 6 to 12 hours
§¥
Vancomycin 15 to 20 mg/kg every 8 to 12 hours
‡

26.  Penetrating injuries : Recommendations for empiric antimicrobial therapy for
purulent meningitis based on patient age and specific predisposing condition
Predisposing factor Common bacterial pathogens Antimicrobial therapy
Age
<1 month
Streptococcus agalactiae, Escherichia
coli, Listeria monocytogenes
Ampicillin plus cefotaxime; OR ampicillin plus
an aminoglycoside
1 to 23 months
Streptococcus pneumoniae, Neisseria
meningitidis, S. agalactiae, Haemophilus
influenzae, E. coli
Vancomycin plus a third-generation
cephalosporin
¶Δ◊
2 to 50 years N. meningitidis, S. pneumoniae
Vancomycin plus a third-generation
cephalosporin
¶Δ◊
>50 years
S. pneumoniae, N. meningitidis, L.
monocytogenes, aerobic gram-negative bacilli
Vancomycin plus ampicillin plus a third-
generation cephalosporin
¶Δ
Head trauma
Basilar skull fracture
S. pneumoniae, H. influenzae, group A beta-
hemolytic streptococci
Vancomycin plus a third-generation
cephalosporin
¶Δ
Penetrating trauma
Staphylococcus aureus, coagulase-negative
staphylococci (especially Staphylococcus
epidermidis), aerobic gram-negative bacilli
(including Pseudomonas aeruginosa)
Vancomycin plus cefepime; OR vancomycin
plus ceftazidime; OR vancomycin plus
meropenem
Postneurosurgery
Aerobic gram-negative bacilli (including P.
aeruginosa), S. aureus, coagulase-negative
staphylococci (especially S. epidermidis)
Vancomycin plus cefepime; OR vancomycin
plus ceftazidime; OR vancomycin plus
meropenem
Immunocompromised state
S. pneumoniae, N. meningitidis, L.
monocytogenes, aerobic gram-negative bacilli
(including P. aeruginosa)
Vancomycin plus ampicillin plus cefepime; OR
vancomycin plus ampicillin plus meropenem

27. OUTCOMES