Basilar fracture management

MEDICAL THERAPY
Adults with simple linear fractures who are neurologically intact do not require any intervention and
may 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, without
antibiotics. Temporal bone fractures are managed conservatively, at least initially, because tympanic
membrane rupture usually heals on its own.
imple depressed fractures in neurologically intact infants are treated e!pectantly. These depressed
fractures heal well and smooth out with time, without elevation. ei"ure medications are
recommended 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 common
recommendation.
Types I and II occipital condylar fractures are treated conservatively with neck stabili"ation, which is
achieved 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 open
depressed fractures require surgical intervention. *ost surgeons prefer to elevate depressed skull
fractures if the depressed segment is more than + mm below the inner table of ad,acent bone.
Indications for immediate elevation are gross contamination, dural tear with pneumocephalus, and an
underlying hematoma. At times, craniectomy is performed if the underlying brain is damaged and
swollen. In these instances, cranioplasty is required at a later date. Another indication for early
surgical intervention is an unstable occipital condylar fracture 'type III) that requires atlantoa!ial
arthrodesis. This can be achieved with inside-outside fi!ation.
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In a retrospective study by Bonfield et al, the ma,ority of pediatric skull fractures were found to be
managed conservatively, and of those requiring surgical intervention, fewer than half of the surgeries
were performed solely for skull fracture repair only. urgical intervention was more likely in patients
who were hit in the head with an ob,ect or were involved in a motor vehicle crash. 1rontal bone
fractures were more likely to necessitate repair, and those patients treated for traumatic brain in,ury
had a greater incidence of # or 2 bones involved in the fracture. *ost of the complications that
occurred were related to the underlying trauma, not the surgery. In addition, none of the patients who
underwent intervention for repair of only skull fracture had a worsening of neurologic status.
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3elayed surgical intervention is required in ossicular incongruences resulting from a longitudinal skull
base 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 persistent
41 leak after a skull base fracture. This requires precise detection of the site of leak before any
surgical 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 the
table, 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 forehead
depressions.
Bony fragments are elevated, and the dura is inspected for any tears. If a dural tear is found, it should
be 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 the
defect. *ethyl methacrylate can be used instead of the bone pieces, but this should be avoided in
children. 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. The
decision to operate is based on the neurological status of the patient, the e!act location of the sinus
involved, and the degree of venous flow compromise. A preoperative angiogram with venous flow
phase or magnetic resonance angiography is recommended whenever a depressed fracture is
thought to be over a venous sinus. 9seful data regarding the position and e!tent of occlusion and
transverse sinus dominance is obtained that can affect decisions regarding surgery.
A neurologically stable patient with a closed depressed fracture over a venous sinus should be
observed. A patient with an open depressed fracture over a patent venous sinus who is neurologically
stable should undergo skin debridement without elevation of the fracture, but if the patient is
neurologically 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 the
sinus 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 pericranium
patch. 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.
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POSTOPERATIVE

DETAILS
&ther than the usual immediate postoperative care, the risk of intracranial hematoma and venous
sinus 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 initial
presentation 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 the
possibility of the skull fracture e!panding.
(atients with contaminated open depressed skull fractures treated surgically should be monitored with
repeat 4T scans a few times over the ne!t #-2 months to check for abscess formation. 1ollow-up also
is dictated by the complications associated with skull fractures, for e!ample, sei"ures, infections, and
removal of bone pieces at the time of initial debridement.
COMPLICATIONS
1ailure to recogni"e skull fracture has more consequences than the complications resulting from
treatment. The chance of a concomitant cervical spine in,ury is /+%, and this should be kept in mind
when 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 to
subepicranial 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 the
bone defect. >epair of such a defect is performed using a split-thickness bone graft. ;rowing skull
fracture has also been reported in literature following a stab wound to a gravid abdomen in the last
trimester.
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A fracture line crossing over a vascular groove, such as the middle meningeal artery, may form an
epidural hematoma.
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imilarly, a fracture line that crosses over a suture may cause sutural diastasis.
Basilar skull fracture
The risk of infection is not high, even without routine antibiotics, especially with 41 rhinorrhea. 1acial
palsy and ossicular chain disruption associated with basilar fractures are discussed in the 4linical
section. 6owever, notably, facial palsy that starts with a #- to 2-day delay is secondary to neurapra!ia
of 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 petrous
temporal bone may involve the gasserian ganglion. An isolated @I cranial nerve in,ury is not a direct
result of fracture, but it may be affected secondarily because of tension on the nerve. 8ower cranial
nerves 'IA, A, AI, and AII) 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 @I
cranial nerves and also may disrupt the internal carotid artery and potentially result in
pseudoaneurysm formation and caroticocavernous fistula 'if it involves venous structures). 4arotid
in,ury 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 developing
sei"ures also e!ists. The overall risk of sei"ures is low but is higher if the patient loses consciousness
for longer than # hours, if an associated dural tear is present, and if the sei"ures start in the first week
of in,ury.