Skull fracture

“ Gunshot wounds of the skull are attended by certain peculiarities. In ordinary circumstances there is usually an external wound and a fracture more or less comminuted, with depression; this wound will almost always require to be enlarged by a simple incision, so as to show the extent of the depression or the size of the broken and depressed portions of bone. When the bone is scarcely injured, and the periosteum is only bruised, or when the bone is even deprived of this covering, it does not follow that it should die or even exfoliate. ”

“ It is probable that in all cases of injury to the head in which a patient loses consciousness, there is some definite damage to the cerebral tissue. This takes the form of a greater or less degree of contusion or laceration, and the lesions are usually most severe and dangerous when the skull is fractured and fragments are driven in upon the brain, but they may exist—indeed they may be very extensive—in the absence of fracture. ”

“ CHAPTER IV. CORRELLY'S STORY. PETER CORRELLY came back from a visit to the hospital where Wilbur Smith was lying.
“A gunshot wound in the right shoulder, two legs broken, a small fracture of the skull, concussion and a few bruises about the body,” he reported. “The body bruises are not important, the shoulder wound is healing, and the only thing that troubles the doctor is the fracture. As it is a skull fracture it may be pretty serious.”
“Has he recovered consciousness?” asked Sharpe, twisting his hands nervously on the blotting pad. ”

“ If it was a common thing to adorn the parapets of houses in towns with piles of loose bricks, it is certain that a large number of persons not immune to fracture of the skull by falling bricks would be eliminated. A time would no doubt come when those with a specific liability to skull fracture would all be eliminated, and the human cranium would have developed a practical immunity to damage from all sorts of falling substances. But there would have been far more extensive suppressions than would appear in the letter of the agreement. ”

“ If the fracture has occurred immediately before the patient’s death, there will be found coagulated blood upon the bones and in the fissures. If the patient has survived for some time, there will be marks of inflammation and, perhaps, pus in contact with the skull, but if a fracture has been made in making the examination, which sometimes happens in even very careful dissectors’ hands, the blood in the fracture will not be coagulated, nor will there be any effusions around the portions. ”

“ In the first instance, careful search should be made for any sign of injury, especially on the head. The discovery of a severe scalp wound or of a fracture of the skull, in association with the symptoms of concussion or compression, will in most cases raise the presumption that the unconsciousness is due to some traumatic intra-cranial lesion. ”

“ Fractures of the vault of the skull may occur without the bone being driven in to compress the brain, and in such cases their existence may be revealed only after death. But if there is also a severe scalp wound the line of fracture may be traced in the bare bone as a thin red crack. ”

“ Thus, the smaller the weapon, the greater the violence, the nearer the site of application to the vertex, the more direct the blow, the greater is the tendency to vault limitation. Again, compound fractures are much more liable to vault limitation than simple fractures, as is proved, for instance, by the reports of Sir Prescott Hewitt—20 compound fractures in which the fracture was restricted to the vault of the skull, and 56 simple fractures in which the base was involved in all but one. ”

“ When both tables are broken, the fracture of the inner is almost always more extensive than that of the outer one, as fissures will extend furthest in the most brittle part. A broken fragment, comprehending the entire thickness of the skull, presents generally a much larger portion of the inner than of the outer table, so much so that the piece would sometimes not admit of removal, though perfectly detached, without enlarging the opening in the outer table. Fractures, with depression of a considerable portion of one of the flat bones, are sometimes unattended with any alarming symptoms. ”

“ A compound fracture will be most readily determined by digital examination, previous to which the scalp-wound must be carefully cleansed. Digital examination is greatly preferable to investigation with the aid of the probe. In any case care must be taken to avoid mistaking one of the sutures of the skull for a fissured fracture. ”

“ A scalp-flap is framed, suited to the occasion and formed with due regard to existent scalp laceration. The fracture being fully exposed, depressed or comminuted fragments of bone are elevated or removed. Complete exposure of the sinus-wall, both in front and behind the site of laceration, is required, and for this purpose the craniectomy forceps may be called into requisition. In the event of copious bleeding during these procedures, strips of gauze should be inserted on either side of the sinus rent between the dura and the bone, thus compressing the sinus and stopping the bleeding. ”

“ Persons have been known to become utterly unconscious by a fracture of the skull, and a portion of it being depressed upon the brain, suspending its action. Perhaps when the accident happened they were in the act of issuing 204an order, or giving directions to those about them. They have lain unconscious for months, and then been relieved by a surgical operation; and when the brain began again to act, and consciousness returned, they have immediately spoken and completed the sentence they were in the act of uttering when they were struck down, months before. ”

“ Fissured fractures in the very young possess another point of interest in that the cleft often tends to increase, this being notably the case when the fracture is associated with injury to underlying dura and brain. The local and general increase of intracranial pressure not only widens the gap, but also leads to thinning and eversion of the margins of the deficiency with possible herniation of brain-matter—traumatic cephalocele. ”

“ Diagnosis.—When the instrument impinges on the head obliquely, after piercing the scalp it may pass for some distance under it before perforating the skull, so that on its withdrawal a valvular wound is left, and at first sight it appears that only the scalp is involved. Sometimes a foreign body left in the gap so fills it up that it is difficult to detect the fracture with a probe or even with the finger. In all doubtful cases the scalp wound should be sufficiently enlarged to exclude such errors. ”

“ They warn about the possibility of fracture of the skull even when there is no penetrating wound of the scalp, and they even suggest the advisability of exploratory incision when there is some good reason for suspicion of, though no evident sign of, fracture. In “Old-Time Makers of Medicine,” I quoted some of the details of this teaching as to head [Pg 92] surgery that may serve to illustrate what these surgeons taught on this important subject. ”

“ Some enumerate also the capillary fracture, but it is a very narrow fissure which eludes the senses, and therefore, being often overlooked owing to the symptoms of it not being obvious, it occasions death. An indentation is not a division of a bone, and, therefore, such an injury is not properly called a fracture, but is, as it were, a protrusion and bending of the skull inwardly, forming a hollow without a solution of continuity, as when vessels made of copper, or the raw hide of an ox, are struck on the outside. ”

“ A man was admitted into the hospital, suffering from profuse hæmorrhage from the ear as the result of a fall down an area. The bleeding continued for fourteen hours, soaking the dressings and continuing so long as the man lived. At the post-mortem examination an extensive comminution of the tegmen tympani was discovered, the fracture being associated with great extra-dural extravasation of blood from a lacerated middle meningeal artery. ”

“ In young persons the brain will bear a greater degree of pressure and of irritation with impunity than it will in persons of mature age. By far the greater number of cases in which recovery has taken place after fracture and depression of the skull with injury of the brain, and even loss of its substance, have occurred in children or in persons under the adult age ”

“ As a rule the whole thickness of the skull is broken, and, as usual, the inner table suffers most. In infants the bones may be merely indented, the fracture being of the greenstick variety. All degrees of severity are met with, from a simple, localised indentation of the bone, to complete smashing of the skull into fragments. ”

“ The nerve-trunks may be contused or torn across, especially in basal fractures which traverse their foramina of exit; blood may be effused into their sheaths as a result of injuries not attended with fracture; or they may be pressed upon by an inflammatory effusion, a tumour, a gumma, or an aneurysm invading the base of the skull. When the nerve is merely contused, or pressed upon by blood-clot, the paralysis tends to pass off in the course of a few days. ”

“ Traumatic cases are treated as soon as possible, other cases receive their dose for two or three days previous to the operation, the drug being continued till all fear of possible meningeal infection has vanished.
In discussing the general treatment of basic fractures, it must be accepted that the basic fracture in itself requires no treatment. Danger or death is dependent on intracranial complications, and an uncomplicated basic fracture demands no active surgical treatment. ”

“ It may be marked in the skull and in the long bones, and in many cases of fracture of the neck of the femur, a moderate amount of lacunar resorption precedes the fracture which results from slight violence. In certain cases this resorptive process in old people is extreme, and leads to great fragility of the bones, with repeated fractures from slight violence, which under ordinary circumstances, would cause no injury at all. ”

“ These three nerves are, however, so protected by their dural sheaths that they generally escape injury. [21]
In the following cases the nerves were involved:—
The patient was admitted suffering from a fracture resulting from a blow on the posterior parietal region. During the next four days no special symptoms developed. On the fifth day, during a sudden attack of dyspnœa and dysphagia, death occurred. A fissured [107] fracture was found which extended into the jugular foramen, a region occupied by blood-clot.
A man committed suicide by means of a pistol-bullet fired through the mouth. ”

“ In all this kind of experimentation upon cadavers for the purpose of eliciting evidence by reproducing as nearly as possible ante-mortem injuries, we must not forget that Casper has strongly insisted that “it is extremely difficult to break up the organic cohesion of dead organs.... If we endeavor to fracture the skull of a dead adult we shall find that an amount of force which if applied in life would indubitably produce fissures if not fracture, or complete crushing of the skull, leaves the dead skull quite uninjured.... ”

“ In addition to the many diseases that afflict the people, there are often injuries. During the winter, snow and ice gather in the toe-holds on the cliffs and climbers, becoming momentarily careless, sometimes crash on the rocks below. Fractured skulls, arms and legs result and their treatment gives the priests some of their most serious problems. Compound fractures result in fatal infections and the medicine men can do little in the case of a serious fracture of the skull. ”

“ Split or crack fractures were also diagnosticated by the methods suggested by Hippocrates of pouring some coloured fluid over the skull after the bone was exposed, when a linear fracture would show by coloration. The Four Masters suggest a sort of red ink for this purpose.
One might well expect that, with trephining as frequent as this textbook of the Four Masters more [Pg 95] than hints, the death-rate of these medieval surgeons must have been very high in head cases. ”

“ The skull has a fracture along the sagittal suture and fractures on the left side of the braincase but these have been glued, and no part of the skull is missing except in the region of the right P4 which part has been shot away. On the left side m2 never developed. Excepting this tooth and the right P4, all the teeth are present and entire. The skin is well made but has the soles of the hind feet turned up. ”

“ Injury to the brain more than corresponded in extent to the fractures of the bone. Pulping of its tissue existed over a wide area both at the points of entrance and of exit. In the former position the amount of damage was the less, the gross changes roughly corresponding with the tissue directly implicated by the bullet itself, and the fragments of bone carried forward by it. The degree of splintering of the skull therefore in great part determined the severity of the lesion. ”