TREATMENT OF FRACTURES OF THE VAULT OF THE SKULL
Indications for operation.
It is the general custom to divide fractures of the vault into two groups—those demanding operative treatment and those in which an expectant attitude is advised—and between these two groups a sharp line of demarcation is drawn. There is, however, no such line of demarcation. In the event of the general condition of the patient being compatible with operative interference, such treatment is urgently called for under the following conditions:—
All cases of punctured fracture.
All cases of depressed fracture, whether diagnosed by palpation or by inference, whether simple or compound, whether complicated or not.
All cases of fracture complicated by extra-dural or localized subdural extravasation of blood.
All elevated fractures.
All compound fractures.
In all these instances, from the presence of depressed fragments of bone, from associated injury to the intracranial contents, or from other causes, no mere expectant policy should be pursued. The surgeon has to look into the future, to bear in mind the possibility of meningeal infection, and the more remote results of head-injuries in general (see [Chapter VI]). In other words, early and active surgical interference is imperatively demanded, for not only is it necessary to strain every endeavour to save the patient’s life, but the surgeon should also adopt those procedures which guard most effectually against the more remote possibilities of the case.
With regard to simple fractures, if it can be determined that the fracture, whether fissured, stellate, or comminuted, is simple and uncomplicated by any serious intracranial lesion, no active surgical treatment is required. The determination of such conditions is, however, quite another matter, always difficult and sometimes, from the presence of overlying hæmatomata, quite impossible.
In the general estimation of these cases it should be borne in mind that simple uncomplicated vault fractures are decidedly rare. For instance, Dwight, in 145 cases of fractured skull that came to autopsy, only found six that evidenced a fissured fracture localized to the vault. It may, of course, be urged that these statistics are fallacious, insomuch as simple uncomplicated vault fractures would probably not come to the post-mortem table. Clinical evidence, however, coincides with Dwight’s statistics, and clinical evidence shows, furthermore, that a blow sufficing to fracture the vault of the skull almost invariably results in further injury.
In these doubtful cases the surgeon is greatly aided in his decision by a general review of the patient’s condition, more especially by those symptoms which are regarded as exemplifying the clinical conditions of concussion, irritation, and compression.
When the fracture is associated with mild concussion
it may be inferred that the brain is practically uninjured, and that operative treatment is not required.
When the fracture is associated with severe concussion
it may be inferred that the brain is damaged, to a degree proportionate to the depth and duration of the stage of unconsciousness. The question of operation depends to a very large extent on the general condition of the patient, and more especially on the temperature and temperature changes (see [p. 114]). With a persistent subnormal temperature it may be inferred that the brain-injury is of a very severe nature, and that operative measures are, for the time being, contra-indicated. In the event of the temperature rising it may be accepted that the patient is passing from the state of shock to that of reaction, operative measures again hinging on the further progress of the case. If the temperature rises progressively, the patient passing from the stage of reaction to that of compression, operative measures are indicated. Under other circumstances an expectant attitude can be adopted.
When the fracture is associated with general cerebral irritation
it may be inferred that the brain is contused or slightly lacerated. Under these circumstances operation is, for the time being, not required, and an expectant attitude should be adopted.
When the fracture is associated with compression
it may be inferred that the condition is dependent on depressed fragments of bone, or on extra- or intra-dural bleeding. Operative measures are now urgently indicated.
When the fracture is confined to the internal table
a diagnosis is only possible when symptoms of localized irritation ensue, either due to pressure exercised on the cortex by spicules of bone or resulting from injury to some intracranial vessel, e. g. the middle meningeal artery. In such cases operation is indicated. Under other circumstances the surgeon must await the developments of the case.
Treatment.
When the fracture is associated with mild concussion.
During the stage of concussion no active treatment is required, beyond putting the patient to bed—with the head low—enveloping him in hot blankets, and applying hot bottles to the extremities. These bottles are wrapped up in flannel: they should never be placed in contact with the patient’s skin. As soon as the reaction stage commences, the bottles and blankets should be removed, the patient covered with light clothing only, and an ice-bag applied to the head, over the region at which the injury was inflicted. Calomel, in suitable doses, should be given by mouth, and a copious enema administered per rectum. Perhaps the most essential point in the general consideration of the case is the after-treatment. The patient should be kept in hospital or home for at least one month, and for the next three months or more, according to the urgency of the case, he should abstain from all mental and bodily work. At the end of that period of time he may return to work, though still kept under observation.
When the fracture is associated with severe concussion.
In the event of persistence of concussion symptoms of a severe type the prognosis is decidedly unfavourable. This prolongation of cerebral shock is undoubtedly dependent in its persistence on severe vaso-motor depression, and in the majority of cases ending unfavourably it will be found that the brain is generally œdematous and regionally contused or lacerated. In cases of this nature the surgeon should confine his attention, for the time being, to an endeavour at terminating this vaso-motor depression, raising the blood-pressure and inducing a definite reaction; the patient being treated after the manner indicated on [p. 118].
When the fracture is associated with general cerebral irritation.
The patient should be put to bed in a quiet and darkened room, under the continuous attention of a trained nurse. An ice-bag or Leiter’s tubes may be applied to the head, though the patient seldom tolerates such attentions. I regard morphia as of the greatest service in this class of cases. It should be given freely, subcutaneously, either by itself or in combination with atropin. I generally order 1⁄4 gr. morphia with 1⁄100 gr. atropin every six hours, till the irritative symptoms subside.
Insomuch as all evidence tends to prove that general cerebral irritation, as resulting from injury, implies a condition of contusion or superficial laceration, a prolonged period of bodily and mental rest is essential before the patient is discharged from treatment and allowed to return to work—a period of not less than six months.
The operative treatment of fractures of the vault.
The usual preparatory treatment is carried out, the scalp-tourniquet applied, a suitable scalp-flap framed and turned down, advantage being taken of all existent scalp lacerations.
The subsequent details vary according to the circumstances of the case:—
Fissured fractures.
If, after thorough exposure of the parts, the operator is satisfied that he has to deal with an uncomplicated fissured fracture, the scalp-flap is accurately sewn into position (see [p. 16]). On the other hand, if the symptoms point to the presence of an extra-dural hæmorrhage, the bone is trephined where the fracture crosses the line of the suspected vessel and the conditions treated as described under middle meningeal hæmorrhage. In subdural extravasation the trephine is applied over that part of the brain, in the immediate vicinity of the fracture, from which the symptoms appear to emanate, and the conditions treated as described under subdural hæmorrhage.
In a certain proportion of cases the symptoms point to a marked increase of intracranial pressure without definite localizing features, a condition pointing to diffuse subdural hæmorrhage, with or without brain laceration. Under such circumstances much may be done to relieve the increased intracranial pressure by carrying out the operation of ‘cerebral decompression’ (see [p. 121]).
Depressed fractures.
The operative details vary according to the nature of the osseous lesion:—
(a) If the depressed fragments of bone are so interlocked that elevation is impossible (e. g. pond and gutter fractures), it will be necessary to trephine in the immediate vicinity of the depression, in order to lessen the mutual attachment of the fragments one to another, so obtaining sufficient purchase for their elevation or removal.
The pericranium is stripped away from the region of the depression (see [Fig. 49]), and a small trephine applied in such a manner that the trephine circle includes the outer part of the depressed area. Care must be taken to avoid more pressure over the depressed fragments than is absolutely necessary, for fear of causing further damage to the underlying structures. This advice is all the more important when it is realized that the fracture of the internal table is almost invariably more extensive than that which involves the visible external table of the skull.
The disk of bone is removed and the conditions investigated with the dural separator. When the degree of depression and the splintering of the internal table are not excessive, the parts may be elevated into position. In most cases, however, the uncertainty that exists with regard to possible dural injury renders it necessary that the depressed fragments should be elevated and removed, or so raised as to allow of adequate inspection of the dura itself. For this purpose the craniectomy forceps may be required. The dura can now be examined. If torn, the opening may require enlargement, in order to determine whether any osseous fragments have been driven into the brain-substance; all such fragments are carefully removed. Hæmorrhage is arrested, the dura sewn up, and the scalp-flap carefully sutured. Drainage should always be avoided, the risk of infection is too great. As a prophylactic against the development of meningeal infection, the patient should undergo the routine treatment with urotropin (see [p. 116]).
(b) When the depression is of such a nature that the elevation of the fragments can be carried out without preliminary trephining, the fragments are raised with the periosteal separator, and the membranes and brain examined as described above.
In simple comminuted fractures the larger fragments of bone are to be replaced in the anticipation that they will live entire, in part, or will act as scaffolding media for the formation of dense fibrous tissue. After removal from the wound, and during the completion of the operation, the vitality of all loose fragments may be preserved by immersion in hot saline solution. All minute fragments of bone should be discarded.
Fig. 49a. The Elevation of a Depressed Fracture. First stage. The trephine circle includes the outer portion of the depressed area.
Fig. 49b. The Elevation of a Depressed Fracture. Second stage. The trephine disk has been removed and the elevator is in position.
With respect to compound fractures, it is necessary that the bone lesion should be fully exposed, all pockets of scalp-tissue being slit up to their termination. Previous to any attempt at examination of the injured bone, further precautions must be taken to avoid subsequent infection, by reason of the bruised and soiled scalp. Such tags of scalp-tissue as appear injured beyond repair should be cut away with the scissors, and in order to avoid or diminish subsequent wound infection, I have been accustomed to swab over the most suspicious parts with pure carbolic acid, washing away the same with saline solution. Since the advent of iodine sterilization, I have often utilized that solution in preference to the carbolic, swabbing the whole surface exposed. I think a combination of the two methods is advisable in more serious cases, utilizing the carbolic for the margins of the wound and iodine for the general surface. By means of this method the risk of meningeal infection and scalp suppuration is greatly reduced. To aid in the prophylaxis, the patient should again be placed under a course of treatment by urotropin (see [p. 116]).
With regard to the bone, all loose fragments should be removed, only those being preserved which retain their pericranial connexions. Even these are thrown back so as to permit of the maximum inspection of the dura mater. This membrane, if torn, is either sewn up at once or opened up more freely in the investigation and removal of underlying blood-clot or bone-débris. After removing such troubles the membrane is accurately sutured. The bone-flaps are now replaced in position. Some surgeons advocate the replacement of the smaller fragments of bone which have previously been removed. These fragments may be sterilized by boiling, but such a process destroys the bone-cells and, in consequence, they become absorbed, merely acting as scaffolding media for the formation of fibrous tissue. Added to that, in the event of suppuration, the presence of such fragments not only leads to the persistence of a purulent discharge, till the fragments are entirely removed, but also increases considerably the risk of meningeal infection.
As a summary, therefore, it may be laid down that it is necessary to remove all loose fragments of bone, the deficiency in the vault being rectified, if necessary, at a later date by one of the methods enumerated in [Chapter VI].
The scalp-flap is accurately sewn up with interrupted salmon-gut sutures, a gauze or cigarette drain being inserted at the most convenient and dependent point, to be removed at the end of forty-eight hours or more according to the progress of the case.
Punctured fractures.
Here there is a special liability to dural laceration and in-driving of comminuted fragments of bone. A full exposure of the parts is therefore absolutely essential. The trephine can be applied in the immediate vicinity of the puncture, or, as is often advisable, in such a manner that the punctured area is included in the trephine circle: this latter method may necessitate that the trephining should be carried out without the aid of the guiding fixation-pin, for which process some experience is needed.
After removal of the bone, the craniectomy forceps may be required, to allow of adequate dural inspection. The dura mater is opened up with blunt-pointed scissors, and the brain examined for in-driven fragments of bone. These, when found, are removed. Deeply situated fragments of bone and foreign bodies may be previously diagnosed by means of an X-ray picture.
If possible, both membrane and scalp should be sutured without drainage, but in the event of possible sepsis, a small cigarette drainage-tube should be inserted so as to lie beneath the dura mater on the one hand and emerge through the scalp wound at the other.
Fractures limited to the external table.
For this class of fracture the reader is referred to the section dealing with bullet-wounds of the skull (see [p. 296]).
Fractures limited to the internal table.
As previously indicated, the diagnosis of this condition is only practicable when the depression of the osseous fragments, or the hæmorrhage resulting from an injured meningeal vessel, so irritate the dura mater and brain that localizing symptoms ensue. For instance, epileptic fits of a Jacksonian type may develop shortly after the accident, this condition demanding a full exposure of the affected region. The operations required in the treatment of traumatic epilepsy and intracranial hæmorrhages are discussed in subsequent chapters.