Compound Depressed Skull Fracture Research Articles

The use of vancomycin powder in the compound depressed skull fractures

Background/aimCompound or open depressed fractures (CDF) is one of the urgent operations of neurosurgery, as it can result in complications of infection. This study is reported to investigate the effect of topical vancomycin powder to the infection rates in the compound depressed skull fractures which have been operated on. Materials and methodsThis present study was conducted on 46 cases with compound depressed skull fractures which have been operated on. Cases were divided into two groups according to the use of subgaleal topical vancomycin powder during the operation. The preoperative and postoperative CRP levels, localization of the fracture, hospitalization time, operation length, dural injury, pneumocephalus, and mortality rates have been examined. ResultsIn cases with dural injury and pneumocephalus, a statistically significant relationship was found between the use of topical vancomycin powder and the frequency of post-op infection (p < 0.001). It was observed that the incidence of postoperative infection was significantly higher in 12 (85.7%) cases with pneumocephalus and dural injury when vancomycin powder was not used. Also, it was observed that the post-operative infection level was significantly higher in fractures in the frontal and parietal regions without vancomycin powder(p < 0.05). ConclusionsThe use of subgaleal topical vancomycin powder is an option to reduce the infection rates and mortality, especially in the cases of compound depressed fractures, which is considered as a dirty wound and prone to infection. It is especially recommended in the presence of dural injury and pneumocephalus.

Cranioplasty for Skull Defects With Polypropylene Abdominal Wall Mesh

Cranioplasty is a well-established common surgery in the practice of neurosurgery and craniofacial surgery. In young patients, complete skull defect closure by bone splitting may be troublesome due to the difficulty to obtain enough bone area. In such cases, sometimes the authors need to use allografts, which may not be widely available in rural practice. In this study, the authors present the series of cranioplasty with polypropylene mesh, which is widely used in abdominal wall closure. Nine patients with depressed compound skull fracture were treated by performing this technique. Selection criteria were: compound depressed skull fractures in which bones were fragmented in a way not able to be reconstructed with and leaving a skull defect, small-sized or relatively medium-sized skull defects, and skull defects not located on the sharp curvatures of the skull which needs firm bended meshes. All patients were male and their ages ranged between 8 months and 36 years.The skull bone defect was reconstructed with polypropylene abdominal wall mesh, which was sutured circumferentially with the galeal tissue. Skull defects were successfully treated in all patients. The follow-up period ranged from 4 to 13 months. One patient with a history of alcoholism and neglectance developed a wound infection after 3 weeks of surgery. This patient was treated successfully with intravenous antibiotics without the need to remove the mesh. There were no complications in the remaining 8 patients. Polypropylene mesh is a cheap and effective material for the reconstruction of small-sized or medium-sized skull defects. It can be a good alternative in rural practice and/or low economic communities, when other cranioplasty materials are not available.

A Prospective Comparative Evaluation of Surgery and Conservative Treatment for Compound Depressed Skull Fractures

The Brain Trauma Foundation issued level III evidence guidelines for surgical management of compound depressed fractures. However, some patients undergo successful conservative treatment. This study compares these 2 treatment modalities. This prospective study included 67 patients with compound depressed skull fractures with surgical indications and a minimum follow-up of 6 months. Depressed fractures in front of the hairline (operated on for cosmetic reasons) and associated with significant intracranial injuries were excluded. Those who gave consent for surgery were included in the surgical group, and those who denied were included in the conservative group. The surgical group had 38 patients and the conservative group had 29. Both groups were comparable in mean age, gender, Glasgow Coma Scale score, head injury severity, depth of fractures, and follow-up duration. Focal neurologic deficits were observed in 19 patients at presentation and were higher in the surgical group. Mean hospital stay was significantly shorter in the conservative group. Mean Glasgow Outcome Scale score at follow-up was statistically similar in both groups (P= 0.13). Focal neurologic deficits improved equally in both groups (P= 0.67). The severity of traumatic brain injury (P= 0.004) and the presence of focal neurologic deficits (P < 0.001) affected the neurologic outcomes. The age, gender, mode of treatment (surgery vs. conservative), surgical site infections, and seizures did not affect neurologic outcomes. The overall complication rates were similar among groups (P= 0.50). New-onset focal neurologic deficits, seizures, and infection rates were not significantly different among the groups (P= 0.98, P= 0.72, P= 0.69). Conservative management has equivalent neurologic outcomes and complications compared with surgical management.

Infection Rate in Pediatric Compound Depressed Fractures FollowingPrimary Replacement of Bone Fragments

AbstractBackground: Compound depressed fractures is one of thecommon neurosurgical emergencies. Children presenting withthis type of head injury, need careful and rapid decision toavoid lifelong morbidities as neurologic deficit. Surgery,according to most authors, is the gold standard in management,however, post-operative wound infection remains a seriouscomplication.Aim of Study: The purpose of this study was to identifyfrequency of infection in pediatric population with compounddepressed skull fractures managed by placement of bone chipsafter cleaning with betadine and antibiotic.Patients and Methods: This study included 41 patientsaged less than 16 years. All patients had Glasgow Coma Scaleof 15. Surgery was done within 24 hours following trauma.Full clinical examination, motor power assessment was andbrain CT scan was done to all patients. Bone fragments wereplaced after cleaning with betadine, saline and gentamicinantibiotic. Patients were assessed for wound infection followingsurgery for the next 3 month.Results: Patients' mean age was 7.8 years, 80.5% of themwere males. The site of the compound depressed fracture wasleft frontal in 36.6% of cases. Fractures were complicated bydural tear in 43.9% of cases. Fall from height was the com-monest mode of trauma in 41.5% of patients. Infection ratewas 7.3% of the cases.Conclusion: The risk of infection in pediatric compounddepressed fractures managed by placement of bone chips aftercleaning with betadine and saline with gentamicin antibioticin the first 24 hours following surgery was low.

Single Stage Debridement and Titanium Mesh Cranioplasty in Patients of Compound Depressed Skull Fracture, an Institutional Experience

Single Stage Debridement and Titanium Mesh Cranioplasty in Patients of Compound Depressed Skull Fracture, an Institutional Experience

An enemy hides in the ceiling; pediatric traumatic brain injury caused by metallic ceiling fan: Case series and literature review

Purpose: We report a series of 29 pediatric patients who sustained head injuries due to metallic ceiling fans. They all were admitted to the Emergency Department of Neurosurgery Teaching Hospital in Baghdad, Iraq, during January 2015 to January 2017.Results: Pediatric ceiling fan head injuries are characterized by four traits which distinguish them from other types of head injuries; 1- Most of them were because of climbing on or jumping from furniture between the ages of two and five. 2- Most of them sustained compound depressed skull fracture which associated with intracranial lesions and pneumocephalus. 3- The most common indication for surgical intervention was because of dirty wound which mixed with hairs. 4- These variables were statistically significantly correlated with the outcome: Level of consciousness, neurologic deficit, fracture site (occipital fracture had worse outcome), intracranial hemorrhage and surgery.Conclusion: Pediatric metallic ceiling fan head injury should be seen as a distinct type of head injury because it has special presentations, managements, and outcomes. In addition, we should start applying preventive methods to minimize its occurrence.

Lumbo Peritoneal Shunt in Management of Cases of Depressed Skull Fractures with Superior Sagittal Sinus Occlusion

AbstractBackground: Patients with depressed skull fractures overlying the superior sagittal sinus (SSS) present an ongoing challenge. Many surgeons would opt for a conservative man-agement of these cases if there was no associated deficit to avoid risky sinus surgery. A variable percentage of patients presenting with such fractures suffer from SSS occlusion resulting in Benign Intracranial Hypertension (BIH).Aim of Study: We aim to evaluate SSS patency, evaluate intracranial tension and evaluate options for management in patients with simple depressed skull fractures overlying posterior 2/3 of SSS and not surgically indicated.Patient and Methods: Prospective study of cases which admitted to Cairo University Hospitals, and Bani sueif Uni-versity Hospital, Department of Neurosurgery, Accidents and Emergency between Jan. 2014 and December 2015.Patients with simple and compound depressed skull frac-tures overlying the SSS and not indicated for surgery, with no other intracranial abnormality, with a Glasgow Coma Scores (GCS) of 12 or better were admitted to the study. Patients underwent Magnetic Resonance Venography (MRV) to determine SSS patency on admission, they were clinically followed up using Computerized Tomography (CT) and repeat MRV when needed. Patients underwent serial lumbar manom-etry, and were given medical treatment in the form of aceta-zolamide, furosemide plus low molecular weight heparin and anti platelets. Patients were then assessed and evaluated to be admitted for LP shunt surgery and followed-up.Results: A total of 12 cases were included in the study, 7 patients had complete SSS occlusion and 5 cases has nar-rowing with patent SSS. The 5 cases with incomplete SSS occlusion had a stable course with only one case (20%) developing elevated intracranial pressure (ICP) not responding to medications and requiring LP shunt. Of the 7 patients with complete occlusion, 100% developed elevated ICP not re-sponding to medical treatment, and all required LP Shunt insertion, 5 patients developed multiple contusions due to anticoagulant therapy on top of SSS occlusion, with discon-tinuation of anticoagulants and deterioration of conscious level, 8 patients had LP surgery and showed a stable improving post operative course, 2 patients had restored SSS patency on repeat MRV.Conclusion: Management of depressed skull fractures overlying the SSS remains controversial, patients with partial occlusion have a better prognosis, patients with complete occlusion can improve with best medical treatment. LP shunt is recommended for all cases of SSS occlusion.

A 100 year review of the evolution in neurosurgical thinking regarding compound depressed skull fractures

A 100 year review of the evolution in neurosurgical thinking regarding compound depressed skull fractures

Predicting Dural Tear in Compound Depressed Skull Fractures: A Prospective Multicenter Correlational Study.

Compound depressed skull fracture (DSF) is a neurosurgical emergency. Preoperative knowledge of dural status is indispensable for treatment decision making. This study aimed to determine predictors of dural tear from clinical and imaging characteristics in patients with compound DSF. This prospective, multicenter correlational study in neurosurgical hospitals in Addis Ababa, Ethiopia, included 128 patients operated on from January 1, 2016, to October 31, 2016. Clinical, imaging, and intraoperative findings were evaluated. Univariate and multivariate analyses were used to establish predictors of dural tear. A logistic regression model was developed to predict probability of dural tear. Model validation was done using the receiver operating characteristic curve. Dural tear was seen in 55.5% of 128 patients. Demographics, injury mechanism, clinical presentation, and site of DSF had no significant correlation with dural tear. In univariate and multivariate analyses, depth of fracture depression (odds ratio 1.3, P < 0.001), pneumocephalus (odds ratio 2.8, P= 0.005), and brain contusions/intracerebral hematoma (odds ratio 5.5, P < 0.001) were significantly correlated with dural tear. We developed a logistic regression model (diagnostic test) to calculate probability of dural tear. Using the receiver operating characteristic curve, we determined the cutoff value for a positive test giving the highest accuracy to be 30% with a corresponding sensitivity of 93.0% and specificity of 43.9%. Dural tear in compound DSF can be predicted with 93.0% sensitivity using preoperative findings and may guide treatment decision making in resource-limited settings where risk of extensive cranial surgery outweighs the benefit.

The frequency of infection in early versus late surgery of compound depressed skull fractures in adults

Background: The treatment of penetrating head injuries and depressed skull fracture has shown a gradual change over the past decades. A proper debridement and closure of scalp wounds and dural tears have been shown to decrease infection and mortality rate of compound skull fractures. This study has been designed to determine the frequency of infection in early versus late surgery of compound depressed skull fractures in adults.Methods: A total of 226 (113 in each group) patients with compound depressed skull fracture were taken. Group A was managed by early surgery while group B underwent late surgery. Data were entered and analyzed using computer program SPSS version 18.Results: Out of these 226 study cases, 143(63.3%) were male, while 83 (36.7%) were females. The mean age of study cases was 37.50±10.58. The mean duration of presentation at the hospital was 6.76±2.41 hours. Roadside accident was noted to be a major etiological factor, i.e. 132 (58.4%) presented with the history of roadside accident. Base of the skull was a major site of wound, i.e. 79 (35.0%). The mean size of the wound was 13.79±3.49cm. Wound infection was seen in 51 (22.56%) of present study cases. Wound infection in group A was seen in 11 (9.7%) out of 113 patients while in group B it was 40 (35.4%) out of 113 patients (p=0.000).Conclusions: The findings of the current study have indicated that early surgery among the targeted population is associated with significantly less frequent wound infection.

Delayed Intracerebral Hemorrhage from a Pseudoaneurysm Following a Depressed Skull Fracture.

A 26-year-old male presented with delayed intracerebral hemorrhage from a ruptured distal middle cerebral artery pseudoaneurysm that followed a compound depressed skull fracture from years ago. The brain protrusion through the skull defect likely resulted in stretching and subsequent tearing of the arterial wall resulting in the pseudoaneurysm formation. No prior report of such a clinical occurrence exists in the literature. We highlight an unusual but treatable cause for intracerebral hemorrhage following surgery for traumatic brain injury.

You Need Not Operate Every Case of Compound Depressed Skull Fracture

You Need Not Operate Every Case of Compound Depressed Skull Fracture

Case Report: Bone fragment in the third ventricle of a 22 year-old woman.

Here we present a very rare case of a woman with a bone fragment in the third ventricle of the brain following compound-depressed skull fractures due to a road traffic accident. There are only few case reports of bullets and textiloma being removed from the third ventricle. Following operative removal of the fragment, the patient was started on cortisol, mineralocorticoid and thyroid hormone replacement. However, the patient eventually died of the severe traumatic hypothalamic insult.

Case Report: Bone fragment in the third ventricle of a 22 year-old woman

Here we present a very rare case of a woman with a bone fragment in the third ventricle of the brain following compound-depressed skull fractures due to a road traffic accident.There are only few case reports of bullets and textiloma being removed from the third ventricle. Following operative removal of the fragment, the patient was started on cortisol, mineralocorticoid and thyroid hormone replacement. However, the patient eventually died of the severe traumatic hypothalamic insult.

Using the head as a mould for cranioplasty with methylmethacrylate.

Methacrylate is a valuable tool to the neurosurgeon, even though it is currently being replaced by custom bone. During cranioplasty in the absence of custom bone, which is preformed based on the patients imaging, one has to make a cast to cover the cranial defect with or without the use of a mould. A good artificial skull outline is necessary for prevention of implant extrusion and acceptable cosmetic outcome. Using the patients head as a mould is a simple, cheap, and useful technique. An incision is made, and either a craniectomy or an attempt at skull elevation or separation of the scalp from dura is done based on the indication for the cranioplasty. The methacrylate monomer is mixed with its solvent. It is placed in between a sliced glove and then thinned out. Several layers of drapes are placed on the patients head, the acrylate which is in between the gloves is then placed on the drapes. As soon as it starts setting and the required shape obtained, it is removed and place on the sterile tray. It is then anchored and the wound closed. This technique produces good cosmetic outcome. However, the head must be properly protected from the risk of burns from the exothermic reaction. The technique is described in a 40-year-old driver who had a compound depressed skull fracture. He had a methylmethacrylate cranioplasty in the 9th week post trauma after allowing for wound healing. We recommend that this technique may be used in centers where custom bone is either too expensive or not available during cranioplasty in order to obtain a good outcome.

Fatal Tetanus Complicating an Untreated Mild Open Head Injury: A Case-Illustrated Review of Cephalic Tetanus

Tetanus is now a rare disease in the Western world, but not so in developing countries. Cephalic tetanus, unlike some other local forms of the disease, is likely to be fatal. We describe the clinical presentation of a case of fatal cephalic tetanus complicating an unattended open non-severe head injury with a review of the literature on the disease. Few cases of cephalic tetanus complicating head injury are found in the world literature, and many were diagnosed late. Cephalic tetanus from open or compound depressed skull fracture is even more rare. Our patient was a young male with an uncertain tetanus immunization history who sustained mild head injury (scalp laceration) and an unattended open depressed skull fracture in a motorcycle crash. He developed cephalic tetanus seven days later, presented late to our service, and died while being prepared for surgical debridement of his cranial wounds. At the immediate post-trauma medical contact, in an across-the-street "clinic," he had received suboptimal care for his head wound and inadequate tetanus prophylaxis. Cephalic tetanus is a rare form of the disease. Although it is preventable easily by well-established medical and surgical treatment paradigms, it continues to catch many clinicians disastrously unaware.

Penetrating skull fracture by a wooden object: Management dilemmas and literature review

Most penetrating skull injuries are caused by gun shot wounds or missiles. The compound depressed skull fracture represents an acute neurosurgical emergency. Management and diagnosis of such cases have been described, but its occurence following a fall onto a piece of wood is quite unusual. A 75-year-old female fell onto a piece of wood that penetrated her skull on the left frontal region and was treated in our department. The patient had no neurological deficits during presentation. She was managed surgically and removal of the wooden object was performed to prevent early or late infection complications. Wooden foreign bodies often pose a different set of challenges as far as penetrating injuries to the brain are concerned. Radiological difficulties and increased rates of infection due to its porous nature make these types of injuries particularly interesting. Their early diagnosis and appropriate treatment can minimize the risk of complications.

Emergency surgical management of traumatic superior sagittal sinus injury: An unusual case

Abstract Head injuries following fall of heavy objects are not very uncommon in developing countries. However, compound depressed skull fracture with superior sagittal sinus (SSS) laceration caused by a flying asbestos fragment in a stormy afternoon is an unusual mode of head injury. We report such an unusual case of compound depressed skull fracture by an asbestos fragment injuring the middle third of SSS and its successful surgical management in a 14-year-old child. The role of computed tomography (CT) scan of head with 3D reconstruction is highlighted. Early steps taken in this case to check the profuse bleeding, which helped save the life of this boy is interesting to note.

Accidental human bite injury leading to compound depressed fracture of skull: Report of an unusual case

Human bites consist of a range of injuries. We present here a 6 year-old-child who suffered a compound depressed fracture of his skull from an accidentally impacted incisor of his father into his head.

Intracranial Retained Stone After Depressed Skull Fracture

In this article, a 9-year-old male patient with a compound depressed skull fracture overlying the superior sagittal sinus and an intracranial stone foreign body is presented. A cerebral penetrating injury caused by a stone is rare. The computed tomography images obtained at standard window widths and window density levels may not reveal a retained stone, which has a chemical structure similar to bone and may not show any artifacts in the computed tomography scans.