Basilar skull fracture

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Basilar skull fracture
Other namesBasal skull fracture, skull base fractures [1]
Tempbonefract.png
A subtle temporal bone fracture as seen on a CT scan
Specialty Emergency medicine, neurosurgery
Symptoms Bruising behind the ears, bruising around the eyes, blood behind the ear drum [1]
Complications Cerebrospinal fluid leak, facial fracture, meningitis [2] [1]
TypesAnterior, central, posterior [1]
Causes Trauma [1]
Diagnostic method CT scan [1]
TreatmentBased on injuries inside the skull [1]
Frequency≈12% of severe head injuries [1]

A basilar skull fracture is a break of a bone in the base of the skull. [1] Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. [1] A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and may result in fluid leaking from the nose or ear. [1] Meningitis occurs in about 14% of cases. [2] Other complications include injuries to the cranial nerves or blood vessels. [1]

Contents

A basilar skull fracture typically requires a significant degree of trauma to occur. [1] It is defined as a fracture of one or more of the temporal, occipital, sphenoid, frontal or ethmoid bone. [1] Basilar skull fractures are divided into anterior fossa, middle fossa and posterior fossa fractures. [1] Facial fractures often also occur. [1] Diagnosis is typically by CT scan. [1]

Treatment is generally based on the extent and location of the injury to structures inside the head. [1] Surgery may be performed to seal a CSF leak that does not stop, to relieve pressure on a cranial nerve or repair injury to a blood vessel. [1] Prophylactic antibiotics do not provide a clinical benefit in preventing meningitis. [2] [3] A basilar skull fracture occurs in about 12% of people with a severe head injury. [1]

Signs and symptoms

Bilateral raccoon eyes Bilateral periorbital ecchymosis (raccoon eyes).jpg
Bilateral raccoon eyes

Pathophysiology

A basilar skull fracture as seen on CT BasSkullFracMark.png
A basilar skull fracture as seen on CT
Diagram showing bones that may be involved in a basilar skull fracture Cranial bones en.svg
Diagram showing bones that may be involved in a basilar skull fracture

Basilar skull fractures include breaks in the posterior skull base or anterior skull base. The former involve the occipital bone, temporal bone, and portions of the sphenoid bone; the latter, superior portions of the sphenoid and ethmoid bones. The temporal bone fracture is encountered in 75% of all basilar skull fractures and may be longitudinal, transverse or mixed, depending on the course of the fracture line in relation to the longitudinal axis of the pyramid. [5]

While not absolute, three principal types of basilar skull fractures are recognized, based on the direction and location of the impacting force:

  1. Longitudinal fracture: This type divides the base of the skull into two halves (right and left). It may result from blunt impact on the face, forehead, back of the head, or from front-to-back crushing forces. [6]
  2. Transverse fracture: This type divides the base of the skull into a front and rear half. It occurs from impact on either side of the head or from side-to-side compression. The fracture typically runs through the petrous portion of the temporal bones and the sella turcica, potentially affecting the pituitary gland. Blood from both ears often indicates this type of fracture, which is the most common basilar skull fracture. Transverse fractures may extend into the orbital roofs or the ethmoid plate, causing periorbital hemorrhage or extensive nasal bleeding, respectively. A fracture through the sella can lead to profuse blood aspiration. A common mechanism for transverse fractures is a sharp blow to the chin, such as a fall onto a hard surface. The impact energy transfers to the skull base via the mandibular rami and temporomandibular joints. The chin injury may appear minor, often just a small abrasion or laceration. [6]
  3. Ring fracture: This type separates the rim of the foramen magnum, the outlet at the base of the skull through which the brain stem exits and becomes the spinal cord, from the rest of the skull base. This may result in injury to the blood vessels and nerves exiting the foramen magnum. [7] This can manifest as loss of facial nerve or oculomotor nerve function, or hearing loss due to damage to cranial nerve VIII. [4] This type of fracture typical results from a fall from height where the victim lands on their feet or buttocks, forcing the skull down onto the vertebral column. [6]

In children, fractures may not occur due to suture separation and greater bone flexibility.

Management

Evidence does not support the use of preventive antibiotics, regardless of the presence of a cerebrospinal fluid leak. [3] [2]

Prognosis

Non-displaced fractures usually heal without intervention. Patients with basilar skull fractures are especially likely to get meningitis. [8] The efficacy of prophylactic antibiotics in these cases is uncertain. [9]

Temporal bone fractures

Acute injury to the internal carotid artery (carotid dissection, occlusion, pseudoaneurysm formation) may be asymptomatic or result in life-threatening bleeding. They are almost exclusively observed when the carotid canal is fractured, although only a minority of carotid canal fractures result in vascular injury. Involvement of the petrous segment of the carotid canal is associated with a relatively high incidence of carotid injury. [10]

Motor racing accidents

Basilar skull fractures are a common cause of death in many motor racing accidents. Drivers who have died as a result of basilar skull fractures include Formula One driver Roland Ratzenberger; IndyCar drivers Bill Vukovich Sr., Tony Bettenhausen Sr., Floyd Roberts, and Scott Brayton; NASCAR drivers Dale Earnhardt Sr., Adam Petty, Tony Roper, Kenny Irwin Jr., Neil Bonnett, John Nemechek, J. D. McDuffie, and Richie Evans; CART drivers Jovy Marcelo, Greg Moore, and Gonzalo Rodriguez; and ARCA drivers Blaise Alexander and Slick Johnson. Ernie Irvan is a survivor of a basilar skull fracture sustained at an accident during practice at the Michigan International Speedway in 1994. [11] Race car drivers Stanley Smith and Rick Carelli also survived a basilar skull fracture. [12] [13]

To prevent basilar skull fractures, many motorsports sanctioning bodies mandate the use of head and neck restraints, such as the HANS device. [14] [15] [16] [17] The HANS device has demonstrated its life-saving abilities multiple times, including Jeff Gordon at the 2006 Pocono 500, Michael McDowell at the Texas Motor Speedway in 2008, [18] Robert Kubica at the 2007 Canadian Grand Prix, and Elliott Sadler at the 2003 EA Sports 500/2010 Sunoco Red Cross Pennsylvania 500. [19]

Related Research Articles

Articles related to anatomy include:

<span class="mw-page-title-main">Ethmoid bone</span> Bone of the facial skeleton

The ethmoid bone is an unpaired bone in the skull that separates the nasal cavity from the brain. It is located at the roof of the nose, between the two orbits. The cubical bone is lightweight due to a spongy construction. The ethmoid bone is one of the bones that make up the orbit of the eye.

<span class="mw-page-title-main">Sphenoid bone</span> Bone of the neurocranium

The sphenoid bone is an unpaired bone of the neurocranium. It is situated in the middle of the skull towards the front, in front of the basilar part of the occipital bone. The sphenoid bone is one of the seven bones that articulate to form the orbit. Its shape somewhat resembles that of a butterfly or bat with its wings extended.

<span class="mw-page-title-main">Occipital bone</span> Bone of the neurocranium

The occipital bone is a cranial dermal bone and the main bone of the occiput. It is trapezoidal in shape and curved on itself like a shallow dish. The occipital bone overlies the occipital lobes of the cerebrum. At the base of the skull in the occipital bone, there is a large oval opening called the foramen magnum, which allows the passage of the spinal cord.

<span class="mw-page-title-main">Temporal bone</span> Bone of the neurocranium

The temporal bones are situated at the sides and base of the skull, and lateral to the temporal lobes of the cerebral cortex.

<span class="mw-page-title-main">Orbit (anatomy)</span> Cavity or socket of the skull in which the eye and its appendages are situated

In anatomy, the orbit is the cavity or socket/hole of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents. In the adult human, the volume of the orbit is 30 millilitres, of which the eye occupies 6.5 ml. The orbital contents comprise the eye, the orbital and retrobulbar fascia, extraocular muscles, cranial nerves II, III, IV, V, and VI, blood vessels, fat, the lacrimal gland with its sac and duct, the eyelids, medial and lateral palpebral ligaments, cheek ligaments, the suspensory ligament, septum, ciliary ganglion and short ciliary nerves.

<span class="mw-page-title-main">Posterior cranial fossa</span> Area of the cranium containing the brainstem and cerebellum

The posterior cranial fossa is the part of the cranial cavity located between the foramen magnum, and tentorium cerebelli. It is formed by the sphenoid bones, temporal bones, and occipital bone. It lodges the cerebellum, and parts of the brainstem.

<span class="mw-page-title-main">Skull fracture</span> Medical condition

A skull fracture is a break in one or more of the eight bones that form the cranial portion of the skull, usually occurring as a result of blunt force trauma. If the force of the impact is excessive, the bone may fracture at or near the site of the impact and cause damage to the underlying structures within the skull such as the membranes, blood vessels, and brain.

<span class="mw-page-title-main">Cranial cavity</span> Space inside the skull formed by eight cranial bones known as the neurocranium

The cranial cavity, also known as intracranial space, is the space within the skull that accommodates the brain. The skull minus the mandible is called the cranium. The cavity is formed by eight cranial bones known as the neurocranium that in humans includes the skull cap and forms the protective case around the brain. The remainder of the skull is called the facial skeleton. Meninges are protective membranes that surround the brain to minimize damage to the brain in the case of head trauma. Meningitis is the inflammation of meninges caused by bacterial or viral infections.

<span class="mw-page-title-main">Greater wing of sphenoid bone</span> Large part of the skull front behind the eye socket

The greater wing of the sphenoid bone, or alisphenoid, is a bony process of the sphenoid bone, positioned in the skull behind each eye. There is one on each side, extending from the side of the body of the sphenoid and curving upward, laterally, and backward.

<span class="mw-page-title-main">Carotid canal</span>

The carotid canal is a passage in the petrous part of the temporal bone of the skull through which the internal carotid artery and its internal carotid (nervous) plexus pass from the neck into the cranial cavity.

<span class="mw-page-title-main">Petrous part of the temporal bone</span> Feature at the base of the human skull

The petrous part of the temporal bone is pyramid-shaped and is wedged in at the base of the skull between the sphenoid and occipital bones. Directed medially, forward, and a little upward, it presents a base, an apex, three surfaces, and three angles, and houses in its interior the components of the inner ear. The petrous portion is among the most basal elements of the skull and forms part of the endocranium. Petrous comes from the Latin word petrosus, meaning "stone-like, hard". It is one of the densest bones in the body. In other mammals, it is a separate bone, the petrosal bone.

<span class="mw-page-title-main">Middle cranial fossa</span>

The middle cranial fossa is formed by the sphenoid bones, and the temporal bones. It lodges the temporal lobes, and the pituitary gland. It is deeper than the anterior cranial fossa, is narrow medially and widens laterally to the sides of the skull. It is separated from the posterior cranial fossa by the clivus and the petrous crest.

<span class="mw-page-title-main">Infratemporal fossa</span> Cavity that is part of the skull

The infratemporal fossa is an irregularly shaped cavity that is a part of the skull. It is situated below and medial to the zygomatic arch. It is not fully enclosed by bone in all directions. It contains superficial muscles, including the lower part of the temporalis muscle, the lateral pterygoid muscle, and the medial pterygoid muscle. It also contains important blood vessels such as the middle meningeal artery, the pterygoid plexus, and the retromandibular vein, and nerves such as the mandibular nerve (CN V3) and its branches.

<span class="mw-page-title-main">Body of sphenoid bone</span>

The body of the sphenoid bone, more or less cubical in shape, is hollowed out in its interior to form two large cavities, the sphenoidal sinuses, which are separated from each other by a septum.

<span class="mw-page-title-main">Clivus (anatomy)</span> Bony part of the skull base

The clivus or Blumenbach clivus is a part of the occipital bone at the base of the skull. It is a shallow depression behind the dorsum sellae of the sphenoid bone. It slopes gradually to the anterior part of the basilar occipital bone at its junction with the sphenoid bone. It extends to the foramen magnum. It is related to the pons and the abducens nerve.

<span class="mw-page-title-main">Le Fort fracture of skull</span> Type of head injury

The Le Fortfractures are a pattern of midface fractures originally described by the French surgeon, René Le Fort, in the early 1900s. He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning. Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat. Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.

<span class="mw-page-title-main">Base of skull</span> Inferior area of the skull, composed of the endocranium and lower parts of the skull roof

The base of skull, also known as the cranial base or the cranial floor, is the most inferior area of the skull. It is composed of the endocranium and the lower parts of the calvaria.

Cerebrospinal fluid rhinorrhoea refers to the drainage of cerebrospinal fluid through the nose (rhinorrhoea). It is typically caused by a basilar skull fracture, which presents complications such as infection. It may be diagnosed using brain scans, and by testing to see if discharge from the nose is cerebrospinal fluid. Treatment may be conservative, but usually involves neurosurgery.

<span class="mw-page-title-main">Hemotympanum</span> Presence of blood in the tympanic cavity of the middle ear

Hemotympanum, or hematotympanum, refers to the presence of blood in the tympanic cavity of the middle ear. Hemotympanum is often the result of basilar skull fracture.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Baugnon, KL; Hudgins, PA (August 2014). "Skull base fractures and their complications". Neuroimaging Clinics of North America. 24 (3): 439–65, vii–viii. doi:10.1016/j.nic.2014.03.001. PMID   25086806.
  2. 1 2 3 4 Nellis, JC; Kesser, BW; Park, SS (January 2014). "What is the efficacy of prophylactic antibiotics in basilar skull fractures?". The Laryngoscope. 124 (1): 8–9. doi: 10.1002/lary.23934 . PMID   24122671.
  3. 1 2 Ratilal, Bernardo O; Costa, João; Pappamikail, Lia; Sampaio, Cristina; Ratilal, Bernardo O (2015). "Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures". The Cochrane Database of Systematic Reviews. 2015 (4): CD004884. doi:10.1002/14651858.CD004884.pub4. PMC   10554555 . PMID   25918919.
  4. 1 2 Pediatric Head Trauma at eMedicine
  5. ↑ Skull Fracture at eMedicine
  6. 1 2 3 Spitz, Werner U.; Spitz, Daniel J.; Fisher, Russell S., eds. (2006). Spitz and Fisher's medicolegal investigation of death: guidelines for the application of pathology to crime investigation (4th ed.). Springfield, Ill: Charles C. Thomas. ISBN   978-0-398-07544-6.
  7. ↑ "About Brain Injury". Brain Injury Association of America. October 12, 2012. Archived from the original on December 13, 2017. Retrieved July 5, 2015.
  8. ↑ Dagi, T.Forcht; Meyer, Frederick B.; Poletti, Charles A. (1983). "The incidence and prevention of meningitis after basilar skull fracture". The American Journal of Emergency Medicine. 1 (3): 295–8. doi:10.1016/0735-6757(83)90109-2. PMID   6680635.
  9. ↑ Butler, John. "Antibiotics in base of skull fractures". BestBets. Retrieved 2014-03-22.
  10. ↑ Resnick, Daniel K.; Subach, Brian R.; Marion, Donald W. (1997). "The Significance of Carotid Canal Involvement in Basilar Cranial Fracture". Neurosurgery. 40 (6): 1177–81. doi:10.1097/00006123-199706000-00012. PMID   9179890.
  11. ↑ https://www.youtube.com/watch?v=ckT7z-XwKUo Dale Jr. Download: Ernie Irvan's Horrific Crash
  12. ↑ Zenor, John (June 9, 2001). "Former Winston Cup driver Smith leaves horrid accident in past". Arizona Daily Sun. Archived from the original on December 10, 2020. Retrieved December 10, 2020.
  13. ↑ Wack, Craig (June 21, 2009). "Rick Carelli's seat safer than '99 Trucks Series ride". The Commercial Appeal . Retrieved 3 February 2010.
  14. ↑ "FIA makes HANS device mandatory". Autosport. Autosport Media UK. 9 December 2005. Retrieved 2 January 2018.
  15. ↑ "NASCAR mandates HANS for 3 series". The Washington Times. The Washington Times LLC. 18 October 2001. Retrieved 2 January 2018.
  16. ↑ "MSA confirms Motor Sports Council decisions regarding Frontal Head Restraints". MSA. Motor Sports Association. Archived from the original on 2 January 2018. Retrieved 2 January 2018.
  17. ↑ "Head and Neck Restraints Mandatory!". NNJR SCCA. Sports Car Club of America. Archived from the original on 3 January 2018. Retrieved 2 January 2018.
  18. ↑ ANDERSON, LARS. "HOW SAFE IS RACING?". SI.com. Retrieved 2018-04-04.
  19. ↑ "Sadler: Sunday's crash hardest in Cup history". ESPN.com. 2010-08-03. Retrieved 2018-04-04.
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