Skull fracture

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Skull fracture
Depressed skull fracture.jpg
A piece of a skull with a depressed skull fracture
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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.

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While an uncomplicated skull fracture can occur without associated physical or neurological damage and is in itself usually not clinically significant, a fracture in healthy bone indicates that a substantial amount of force has been applied and increases the possibility of associated injury. Any significant blow to the head results in a concussion, with or without loss of consciousness.

A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges, or runs through the paranasal sinuses and the middle ear structures, bringing the outside environment into contact with the cranial cavity is called a compound fracture. Compound fractures can either be clean or contaminated.

There are four major types of skull fractures: linear, depressed, diastatic, and basilar. Linear fractures are the most common, and usually require no intervention for the fracture itself. Depressed fractures are usually comminuted, with broken portions of bone displaced inward—and may require surgical intervention to repair underlying tissue damage. Diastatic fractures widen the sutures of the skull and usually affect children under three. Basilar fractures are in the bones at the base of the skull.

Types

Linear fracture

Linear skull fractures are breaks in the bone that transverse the full thickness of the skull from the outer to inner table. They are usually fairly straight with no bone displacement. The common cause of injury is blunt force trauma where the impact energy transferred over a wide area of the skull.[ citation needed ]

Linear skull fractures are usually of little clinical significance unless they parallel in close proximity or transverse a suture, or they involve a venous sinus groove or vascular channel. The resulting complications may include suture diastasis, venous sinus thrombosis, and epidural hematoma. In young children, although rare, the possibility exists of developing a growing skull fracture especially if the fracture occurs in the parietal bone. [1]

Depressed fracture

Depressed skull fracture Depressed skull fracture2.jpg
Depressed skull fracture

A depressed skull fracture is a type of fracture usually resulting from blunt force trauma, such as getting struck with a hammer, rock or getting kicked in the head. These types of fractures—which occur in 11% of severe head injuries—are comminuted fractures in which broken bones displace inward. Depressed skull fractures present a high risk of increased pressure on the brain, or a hemorrhage to the brain that crushes the delicate tissue.[ citation needed ]

Compound depressed skull fractures occur when there is a laceration over the fracture, putting the internal cranial cavity in contact with the outside environment, increasing the risk of contamination and infection. In complex depressed fractures, the dura mater is torn. Depressed skull fractures may require surgery to lift the bones off the brain if they are pressing on it by making burr holes on the adjacent normal skull. [2]

Diastatic fracture

Cranial abnormalities in cleidocranial dysplasia including diastatic sutures Cleidocranial2.jpg
Cranial abnormalities in cleidocranial dysplasia including diastatic sutures

Diastatic fractures occur when the fracture line transverses one or more sutures of the skull causing a widening of the suture. While this type of fracture is usually seen in infants and young children as the sutures are not yet fused it can also occur in adults. When a diastatic fracture occurs in adults it usually affects the lambdoidal suture as this suture does not fully fuse in adults until about the age of 60. Most adult diastatic fractures are caused by severe head injuries. Due to the trauma, diastatic fracture occurs with the collapse of the surrounding head bones. It crushes the delicate tissue, similarly to a depressed skull fracture.[ citation needed ]

Diastatic fractures can occur with different types of fractures and it is also possible for diastasis of the cranial sutures to occur without a concomitant fracture. Sutural diastasis may also occur in various congenital disorders such as cleidocranial dysplasia and osteogenesis imperfecta. [3] [4] [5] [6]

Basilar fracture

Superior view of the skull base Schadelbasis1.jpg
Superior view of the skull base

Basilar skull fractures are linear fractures that occur in the floor of the cranial vault (skull base), which require more force to cause than other areas of the neurocranium. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients.

Basilar fractures have characteristic signs: blood in the sinuses; cerebrospinal fluid rhinorrhea (CSF leaking from the nose) or from the ears (cerebrospinal fluid otorrhea); periorbital ecchymosis often called 'raccoon eyes' [7] (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and retroauricular ecchymosis known as "Battle's sign" (bruising over the mastoid process). [8]

Growing fracture

A growing skull fracture (GSF) also known as a craniocerebral erosion or leptomeningeal cyst [9] due to the usual development of a cystic mass filled with cerebrospinal fluid is a rare complication of head injury usually associated with linear skull fractures of the parietal bone in children under 3. It has been reported in older children in atypical regions of the skull such as the basioccipital and the base of the skull base and in association with other types of skull fractures. It is characterized by a diastatic enlargement of the fracture.[ citation needed ]

Various factors are associated with the development of a GSF. The primary causative factor is a tear in the dura mater. The skull fracture enlarges due, in part, to the rapid physiologic growth of the brain that occurs in young children, and brain cerebrospinal fluid (CSF) pulsations in the underlying leptomeningeal cystic mass. [10] [11] [12] [13] [14] [15] [16]

Cranial burst fracture

A cranial burst skull fracture, usually occurring with severe injuries in infants less than 1 year of age, is a closed, diastatic skull fracture with cerebral extrusion beyond the outer table of the skull under the intact scalp.[ citation needed ]

Acute scalp swelling is associated with this type of fracture. In equivocal cases without immediate scalp swelling the diagnosis may be made via the use of magnetic resonance imaging thus insuring more prompt treatment and avoiding the development of a "growing skull fracture". [17]

Compound fracture

Compound skull fractures occur when all layers protecting the brain have been breached from the epidermis to the meninges allowing outside environmental contact with the skull cavity. Meninges-en.svg
Compound skull fractures occur when all layers protecting the brain have been breached from the epidermis to the meninges allowing outside environmental contact with the skull cavity.

A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges—or runs through the paranasal sinuses and the middle ear structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.[ citation needed ]

Compound fractures may either be clean or contaminated. Intracranial air (pneumocephalus) may occur in compound skull fractures. [18]

The most serious complication of compound skull fractures is infection. Increased risk factors for infection include visible contamination, meningeal tear, loose bone fragments and presenting for treatment more than eight hours after initial injury. [19]

Compound elevated fracture

A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull. This type of skull fracture is always compound in nature. It can be caused during an assault with a weapon where the initial blow penetrates the skull and the underlying meninges and, on withdrawal, the weapon lifts the fractured portion of the skull outward. It can also be caused by the skull rotating while being struck in a case of blunt force trauma, the skull rotating while striking an object as in a fall, or it may occur during transfer of a patient after an initial compound head injury. [20] [21]

Anatomy

Cranial bones en.svg
Lateral view of the human skull with the neurocranium highlighted
Three bone layers of the cranial vault.jpg
The three bone layers of the skull

The human skull is anatomically divided into two parts: the neurocranium, formed by eight cranial bones that houses and protect the brain—and the facial skeleton (viscerocranium) composed of fourteen bones, not including the three ossicles of the inner ear. [22] The term skull fracture typically means fractures to the neurocranium, while fractures of the facial portion of the skull are facial fractures , or if the jaw is fractured, a mandibular fracture . [23]

The eight cranial bones are separated by sutures  : one frontal bone, two parietal bones, two temporal bones, one occipital bone, one sphenoid bone, and one ethmoid bone. [24]

The bones of the skull are in three layers: the hard compact layer of the external table ( lamina externa ), the diploë (a spongy layer of red bone marrow in the middle, and the compact layer of the inner table (Lamina interna). [25]

Skull thickness is variable, depending on location. Thus the traumatic impact required to cause a fracture depends on the impact site. The skull is thick at the glabella, the external occipital protuberance, the mastoid processes, and the external angular process of the frontal bone. Areas of the skull that are covered with muscle have no underlying diploë formation between the internal and external lamina, which results in thin bone more susceptible to fractures.[ citation needed ]

Skull fractures occur more easily at the thin squamous temporal and parietal bones, the sphenoid sinus, the foramen magnum (the opening at the base of the skull that the spinal cord passes through), the petrous temporal ridge, and the inner portions of the sphenoid wings at the base of the skull. The middle cranial fossa, a depression at the base of the cranial cavity forms the thinnest part of the skull and is thus the weakest part. This area of the cranial floor is weakened further by the presence of multiple foramina; as a result this section is at higher risk for basilar skull fractures to occur. Other areas more susceptible to fractures are the cribriform plate, the roof of orbits in the anterior cranial fossa, and the areas between the mastoid and dural sinuses in the posterior cranial fossa. [26]

Prognosis

Children with a simple skull fracture without other concerns are at low risk of a bad outcome and rarely require aggressive treatment. [27]

The presence of a concussion or skull fracture in people after trauma without intracranial hemorrhage or focal neurologic deficits was indicated in long term cognitive impairments and emotional lability at nearly double the rate as those patients without either complication. [28]

Those with a skull fracture were shown to have "neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS". [29]

See also

Related Research Articles

<span class="mw-page-title-main">Skull</span> Bony structure that forms the head in vertebrates

The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone, however two parts are more prominent: the cranium and the mandible. In humans, these two parts are the neurocranium (braincase) and the viscerocranium that includes the mandible as its largest bone. The skull forms the anterior-most portion of the skeleton and is a product of cephalisation—housing the brain, and several sensory structures such as the eyes, ears, nose, and mouth. In humans, these sensory structures are part of the facial skeleton.

<span class="mw-page-title-main">Occipital bone</span> Skull bone, lower back of cranium

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">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

<span class="mw-page-title-main">Intracranial hemorrhage</span> Hemorrhage, or bleeding, within the skull

Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds.

<span class="mw-page-title-main">Epidural hematoma</span> Build-up of blood between the dura mater and skull

Epidural hematoma is when bleeding occurs between the tough outer membrane covering the brain and the skull. Often there is loss of consciousness following a head injury, a brief regaining of consciousness, and then loss of consciousness again. Other symptoms may include headache, confusion, vomiting, and an inability to move parts of the body. Complications may include seizures.

<span class="mw-page-title-main">Foramen lacerum</span> Triangular hole in the base of the skull

The foramen lacerum is a triangular hole in the base of skull. It is located between the sphenoid bone, the apex of the petrous part of the temporal bone, and the basilar part of the occipital bone.

<span class="mw-page-title-main">Crown (anatomy)</span> Top of the head

The crown is the top portion of the head behind the vertex. The anatomy of the crown varies between different organisms. The human crown is made of three layers of the scalp above the skull. The crown also covers a range of bone sutures, and contains blood vessels and branches of the trigeminal nerve.

<span class="mw-page-title-main">Superior orbital fissure</span> Foramen in the skull allowing for passage of cranial nerves

The superior orbital fissure is a foramen or cleft of the skull between the lesser and greater wings of the sphenoid bone. It gives passage to multiple structures, including the oculomotor nerve, trochlear nerve, ophthalmic nerve, abducens nerve, ophthalmic veins, and sympathetic fibres from the cavernous plexus.

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

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

Craniofacial surgery is a surgical subspecialty that deals with congenital and acquired deformities of the head, skull, face, neck, jaws and associated structures. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific; craniofacial surgeons deal with bone, skin, nerve, muscle, teeth, and other related anatomy.

<span class="mw-page-title-main">Raccoon eyes</span> Medical condition

Raccoon eyes or periorbital ecchymosis is a sign of basal skull fracture or subgaleal hematoma, a craniotomy that ruptured the meninges, or (rarely) certain cancers. Bilateral hemorrhage occurs when damage at the time of a facial fracture tears the meninges and causes the venous sinuses to bleed into the arachnoid villi and the cranial sinuses. In lay terms, blood from skull fracture seeps into the soft tissue around the eyes. Raccoon eyes may be accompanied by Battle's sign, an ecchymosis behind the ear. These signs may be the only sign of a skull fracture, as it may not show on an X-ray. They normally appear between 48 and 72 hours after the injury. It is recommended that the patient not blow their nose, cough vigorously, or strain to prevent further tearing of the meninges.

<span class="mw-page-title-main">Foramen spinosum</span> Hole in the sphenoid bone of the skull

The foramen spinosum is a small open hole in the greater wing of the sphenoid bone that gives passage to the middle meningeal artery and vein, and the meningeal branch of the mandibular nerve.

Cleidocranial dysostosis (CCD), also called cleidocranial dysplasia, is a birth defect that mostly affects the bones and teeth. The collarbones are typically either poorly developed or absent, which allows the shoulders to be brought close together. The front of the skull often does not close until later, and those affected are often shorter than average. Other symptoms may include a prominent forehead, wide set eyes, abnormal teeth, and a flat nose. Symptoms vary among people; however, intelligence is typically unaffected.

<span class="mw-page-title-main">Carotid canal</span> Hole in the temporal bone in the skull for the internal carotid artery to enter the skull

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">Occipital condyles</span> Undersurface protuberances of the occipital bone in vertebrates

The occipital condyles are undersurface protuberances of the occipital bone in vertebrates, which function in articulation with the superior facets of the atlas vertebra.

In arthropod and vertebrate anatomy, the vertex is the highest point of the head.

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">Facial trauma</span> Medical condition

Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.

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

The zygomaticomaxillary complex fracture, also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture, has four components, three of which are directly related to connections between the zygoma and the face, and the fourth being the orbital floor. Its specific locations are the lateral orbital wall, separation of the maxilla and zygoma at the anterior maxilla, the zygomatic arch, and the orbital floor near the infraorbital canal.

Dural tear is a tear occurring in the dura mater of the brain. It is usually caused as a result of trauma or as a complication following surgery.

References

  1. ↑ Haar FL (October 1975). "Complication of linear skull fracture in young children". Am. J. Dis. Child. 129 (10): 1197–200. doi:10.1001/archpedi.1975.02120470047013. PMID   1190143.
  2. ↑ Singh J and Stock A. 2006. "Head Trauma." Emedicine.com. Retrieved on January 26, 2007.
  3. ↑ Paterson CR, Burns J, McAllion SJ (January 1993). "Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form". Am. J. Med. Genet. 45 (2): 187–92. doi:10.1002/ajmg.1320450208. PMID   8456801.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ↑ Kanda M, Kabe S, Kanki T, Sato J, Hasegawa Y (December 1997). "[Cleidocranial dysplasia: a case report]". No Shinkei Geka. 25 (12): 1109–13. PMID   9430147.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ↑ Sabini RC, Elkowitz DE (October 2006). "Significance of differences in patency among cranial sutures". J Am Osteopath Assoc. 106 (10): 600–4. PMID   17122029.
  6. ↑ Pirouzmand F, Muhajarine N (January 2008). "Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology". J Craniofac Surg. 19 (1): 27–36. doi:10.1097/SCS.0b013e31815ca07a. PMID   18216661. S2CID   7154559.
  7. ↑ Herbella FA, Mudo M, Delmonti C, Braga FM, Del Grande JC (December 2001). "'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture". Injury. 32 (10): 745–7. doi:10.1016/s0020-1383(01)00144-9. PMID   11754879.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ↑ Tubbs RS, Shoja MM, Loukas M; et al. (Jan 2010). "William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture". J Neurosurg. 112 (1): 186–8. doi:10.3171/2008.8.JNS08241. PMID   19392601.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ↑ Irabor PF, Akhigbe AO (2010). "Leptomeningeal cyst in a child after head trauma: a case report". West Afr J Med. 29 (1): 44–6. PMID   20496339.
  10. ↑ Gupta SK, Reddy NM, Khosla VK; et al. (1997). "Growing skull fractures: a clinical study of 41 patients". Acta Neurochir (Wien). 139 (10): 928–32. doi:10.1007/bf01411301. PMID   9401652. S2CID   24991254.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ↑ Ersahin Y, Gülmen V, Palali I, Mutluer S (September 2000). "Growing skull fractures (craniocerebral erosion)". Neurosurg Rev. 23 (3): 139–44. doi:10.1007/pl00011945. PMID   11086738. S2CID   22659384.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ↑ Muhonen MG, Piper JG, Menezes AH (April 1995). "Pathogenesis and treatment of growing skull fractures". Surg Neurol. 43 (4): 367–72, discussion 372–3. doi:10.1016/0090-3019(95)80066-p. PMID   7792708.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ↑ Caffo M, Germanò A, Caruso G, Meli F, Calisto A, Tomasello F (March 2003). "Growing skull fracture of the posterior cranial fossa and of the orbital roof". Acta Neurochir (Wien). 145 (3): 201–8, discussion 208. doi:10.1007/s00701-002-1054-y. PMID   12632116. S2CID   5665654.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ↑ Ziyal IM, Aydin Y, Türkmen CS, Salas E, Kaya AR, Ozveren F (1998). "The natural history of late diagnosed or untreated growing skull fractures: report on two cases". Acta Neurochir (Wien). 140 (7): 651–4. doi:10.1007/s007010050158. PMID   9781277. S2CID   18879100.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ↑ Locatelli D, Messina AL, Bonfanti N, Pezzotta S, Gajno TM (July 1989). "Growing fractures: an unusual complication of head injuries in pediatric patients". Neurochirurgia (Stuttg). 32 (4): 101–4. doi:10.1055/s-2008-1054014. PMID   2770958. S2CID   44468528.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ↑ Pezzotta S, Silvani V, Gaetani P, Spanu G, Rondini G (1985). "Growing skull fractures of childhood. Case report and review of 132 cases". J Neurosurg Sci. 29 (2): 129–35. PMID   4093801.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ↑ Donahue DJ, Sanford RA, Muhlbauer MS, Chadduck WM (December 1995). "Cranial burst fracture in infants: acute recognition and management". Childs Nerv Syst. 11 (12): 692–7. doi:10.1007/BF00262233. PMID   8750951. S2CID   26744592.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ↑ Fundamentals of diagnostic radiology by William E. Brant, Clyde A. Helms p.56
  19. ↑ Rehman L, Ghani E, Hussain A; et al. (Mar 2007). "Infection in compound depressed fracture of the skull". J Coll Physicians Surg Pak. 17 (3): 140–3. PMID   17374298.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ↑ Elevated skull fracture[www.ijntonline.com/Dec07/abstracts/abs12.PDF]
  21. ↑ Adeolu AA, Shokunbi MT, Malomo AO, Komolafe EO, Olateju SO, Amusa YB (May 2006). "Compound elevated skull fracture: a forgotten type of skull fracture". Surg Neurol. 65 (5): 503–5. doi:10.1016/j.surneu.2005.07.010. PMID   16630918.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ↑ Anne M. Gilroy: : Atlas of Anatomy. P.454; Thime Medical Publishers Inc. (2008) ISBN   1-60406-151-0
  23. ↑ Olson RA, Fonseca RJ, Zeitler DL, Osbon DB (January 1982). "Fractures of the mandible: a review of 580 cases". J. Oral Maxillofac. Surg. 40 (1): 23–8. doi:10.1016/s0278-2391(82)80011-6. PMID   6950035.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ↑ Leon Schlossberg, George D. Zuidema, Johns: The Johns Hopkins Atlas of Human Functional Anatomy, p.5; The Johns Hopkins University Press; (1997) ISBN   0-8018-5652-3
  25. ↑ Johannes Lang: Skull base and related structures: atlas of clinical anatomy. P.208. F.K.Schattauer, Germany;(July 1999) ISBN   3-7945-1947-7
  26. ↑ Medscape: Ali Nawaz Khan: Imaging in Skull Fractures
  27. ↑ Bressan, S; Marchetto, L; Lyons, TW; Monuteaux, MC; Freedman, SB; Da Dalt, L; Nigrovic, LE (23 November 2017). "A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children". Annals of Emergency Medicine. 71 (6): 714–724.e2. doi:10.1016/j.annemergmed.2017.10.014. PMC   10052777 . PMID   29174834. S2CID   205548333.
  28. ↑ Jackson JC, Obremskey W, Bauer R; et al. (January 2007). "Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage". J Trauma. 62 (1): 80–8. doi:10.1097/TA.0b013e31802ce9bd. PMID   17215737.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  29. ↑ Smith-Seemiller L, Lovell MR, Smith S, Markosian N, Townsend RN (March 1997). "Impact of skull fracture on neuropsychological functioning following closed head injury". Brain Inj. 11 (3): 191–6. doi:10.1080/026990597123638. PMID   9058000.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Bibliography

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