Key-words:
Compound - elevated - fracture skull - Glasgow Outcome Score
Introduction
Elevated skull fracture is an atypical type of fracture with very few cases has been
reported in different literature. The classification of skull bone fracture is based
on type (open fracture and closed fracture), site (depressed fracture and basal fracture),
and pattern (linear, diastatic, and comminuted).[[1]] The different variety of fracture depends on the shape of impacting object, mechanism
of force, and site of impact over skull. In 1650–1550 BC, elevated fracture of skull
was first described in the renowned surgical treatise “The Edwin Smith surgical papyrus.”[[2]] It was described as fracture in which fractured fragment is elevated above the
level of the intact skull.[[3]] Owing to the rarity of occurrence or neglect, this fracture remained unreported
in surgical texts till as late as 1976 when Ralston mentioned its occurrence and reviewed
the pathology.[[4]] 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 the skull rotating while being
struck in a case of blunt force trauma, the skull rotating while striking an inanimate
object as in a fall, or it may occur during transfer of a patient after an initial
compound head injury.
Materials and Methods
This is a prospective study conducted over period of 4 years from January 2014 to
January 2018 at tertiary care center in the Department of neurosurgery at RNT Medical
College and M. B. Hospital, Udaipur, Rajasthan, India. During this period, the total
patient admitted of head injury is 10951, so the incidence of compound elevated skull
fracture (CESF) in our series is 0.091% which is very less compared to previous literature.
Recorded documents were prospectively studied for age of distribution, sex, mode of
injury, site of injury, mechanism of injury, clinical profile, radiological investigations,
neurosurgical management, and outcome asses by Glasgow Outcome Scale at the time of
discharge and at the age of 6 months. Postoperatively, the patients were followed
up clinically and radiologically at a regular interval. Postoperative computed tomography
(CT) scan was performed in the immediate postoperative period.
Results
During this period, total patients admitted of head injury are 10951. Out of which
10 patients had CESF, six are males and four are females. Male to female ratio was
3:2. Their age range was 20–45 years (mean age 31.1 years). Six patients were lies
in 20–30 years of age group, three were in between 31–40 years, while one patient
was 45 years old [[Table 1]]. The most common mode of injury was Road traffic accident (RTA) in 60% (n = 6)
followed by fall from height in 20% (n = 2) and Assault in 20% (n = 2) by sharp-edged
objects (sword) [[Table 2]]. The fracture was compound type in all 10 patients. All of them had scalp wound
directly overlying the calvarial fracture segment, and scalp wound length range was
5–15 cm, dural tears were seen in two out of ten patients. After hemodynamic stabilization,
all patients underwent the Noncontrast Computed Tomography (NCCT) brain with bone
window. Wound exploration, cleaning, debridement, and reduction of fracture segment
were done in eight cases, frontal bone craniotomy and extradural hematoma removal
were done in one case, frontal bone craniotomy with evacuation of pneumocephalus was
done one case postoperative course was uneventful and outcome was good (GOS 5) in
8 (80%) cases.
Table 1: Age distribution
Table 2: Mode of injury
At the time of presentation, five patients had mild head injury (Glasgow Coma Scale
Score (GCS 13–15), five had moderate head injury (GCS 9–12) [[Table 3]]. Elevated frontal bone fracture on the right side is seen in 7 (70%) patients,
whereas parietal bone fracture was seen in 3 (30%) cases [[Table 3]]. Among the associated NCCT head finding, pneumocephalus [[Figure 1]]a was most common, present in three cases followed by contusion in two cases, extradural
hematoma in one case and intracranial hematoma in one case. The dural tear was seen
in two patients.
Table 3: Clinical-radiological condition and Glasgow Outcome Score at the time of discharge
and age 6 month
Figure 1: (a) Noncontrast Computed Tomography head showing right frontal bone elevated fracture
with bilateral pneumocephalus, (b) Noncontrast Computed Tomography Head bone window
showing right frontal bone elevated fracture, (c) postoperative Noncontrast Computed
Tomography scan showing reduced fracture segment
Frontal bone craniotomy with evacuation of pneumocephalus was done one case [[Figure 1]]a, [[Figure 1]]b and [[Figure 1]]c whereas exploration, cleansing, debridement, and reduction of fracture segment
were done in 8 cases [[Figure 2]]a,[[Figure 2]]b,[[Figure 2]]c, [[Figure 3]], [[Figure 4]]a, [[Figure 4]]b, [[Figure 5]] and [[Figure 6]].
Figure 2: (a) Noncontrast Computed Tomography head showing elevated right frontal bone fracture,
(b) intraoperative image showing elevated fracture, (c) intraoperative image after
reduction of elevated fracture
Figure 3: Noncontrast Computed Tomography brain bone window showing elevated right parietal
bone fracture
Figure 4: (a) Noncontrast Computed Tomography brain showing elevated fracture of the right
parietal bone with intracranial hematoma, (b) Noncontrast Computed Tomography bone
window showing right parietal bone elevated fracture
Figure 5: Noncontrast Computed Tomography brain showing elevated fracture of the right Frontal
bone with bilateral pneumocephalus with underlying small extradural hematoma with
contusion
Figure 6: Noncontrast Computed Tomography brain showing elevated fracture of the right Frontal
bone
Good recovery was noted in 8 (80%) cases (GOS 5) [[Table 3]], severe disability seen in one patient which was admitted for prolong time and
improvement was delayed due poor GCS score at time of admission (GOS 3 at the time
of discharge and GOS 4 at 6-month follow-up), and one patient was expired (GOS 1)
[[Table 3]] because of poor GCS during admission and ventilator-associated pneumonia. All nine
patients are on a regular follow-up recovered well.
Discussion
The principles for the management for all type of fracture either CESFs or other type
of skull fracture are same that is, early diagnosis and prompt intervention with the
use of broad-spectrum antibiotics, wound debridement, and irrigation, removal of the
foreign body and loose bone fragments and watertight dural repair).[[4]],[[5]],[[6]],[[7]] Whenever delay in performing the surgery, it may lead to intracranial infection,
meningitis, brain abscess, bone flap osteomyelitis, surgical site infection, wound
gap, and poor outcome. Elevated fracture has more favorable outcome if it is not associated
with underlying brain parenchymal injury. The outcome is also depends on GCS at time
of admission and postoperative infection. The mechanisms behind such type of injuries
are the lateral pull of the object or head rotation during the impact, as happens
in head injuries sustained with long, sharp-edged objects such as propeller or machete.[[8]],[[9]] Another mechanism might be the elevation of the free fragment while attempts are
made to remove the offending object or while the patient is transferred, described
in few literature.[[8]] There are very few references of elevated skull fracture in literature. We compared
our patients with other published reports. Exclusive male gender involvement is related
to their involvement in outdoor activities more than females. Modes of injury in Adeolu
et al., series were assault, domestic accident, and RTA.[[8]] In patients with “CESF,” make it highly vulnerable to develop several complications
(e.g., meningitis, brain abscess formation, or cerebrospinal fluid fistula [CSF])
and any delay in intervention can be catastrophic and can alter the prognosis.[[9]],[[10]],[[11]] Dura may be intact in elevated skull fracture as mentioned by Borkar et al.[[9]] In our series dural tear seen in two patients. It has been documented by some literature
that elevated fractures are always compound in nature.[[12]]
Noncontract CT Scan of the head with bone window is the investigation of choice in
all age groups of elevated skull fracture patients because it reveals bony abnormality
as well as any underlying hematoma and brain parenchymal lesions.[[1]],[[13]] Compound elevated fractures should be managed as compound depressed fracture with
extensive debridement of wound, elevated bones fragment repositioned or remove after
the evacuation of hematoma or contusion, with proper wash and closure of dura. Like
for any other compound injury, early recognition, and adequate treatment of elevated
skull fracture subgroup will prevent avoidable complications like intracranial sepsis
or CSF fistula, and thus will reduce the morbidity and mortality.[[10]] Pediatric patients are more susceptible for the secondary insult of the brain from
low oxygen saturation, fluid imbalances, electrolyte disturbances, fever, and seizures
requiring special care. Extensive medical literature search by our group shows that
almost all reported cases of elevated skull fracture report adults.[[4]],[[8]],[[9]],[[10]],[[11]],[[12]] Chhiber et al. Reported two cases of elevated fractures in pediatric age group.[[11]] Key elements of surgery are evacuation of hematomas, dural repair, further decompression
(if brain is tense and bulging), thorough debridement and judicious replacement of
elevated bone segment (depending on the degree of contamination, protrusion of brain,
and adequacy of debridement), and a scalp repair over a subgaleal or extradural drain.[[9]],[[13]] Wound contamination may be relatively less in this group of fractures owing to
tangential direction of impact which would introduce less amount of foreign material
in the wound as compared to depressed skull fractures tangential force acting on the
intact calvarium in association with rotation of the head.[[9]],[[12]] The amount of force transmitted to the brain and its overlying structures is more
when applied force is perpendicular to the brain's surface in comparison to when the
force is applied tangentially.[[8]] Thus, injury to brain and associated structures may be less severe in elevated
fracture having tangential impact compared to depressed fractures having a perpendicular
impact.[[8]] Depressed fracture of skull may be more contaminated than the elevated fracture
of skull because the perpendicular direction of force drives more dirt in the wound
than the tangential direction of the force. Hence, patients of depressed fractures
are more prone for infectious complications than those with elevated fractures. Rarely,
presentations are complicated with intraventricular hemorrhage and superior sagittal
sinus occlusion.[[7]],[[10]] Although a few pediatric cases have been reported, none of them have quoted a long-term
follow-up data.[[14]]
Conclusion
Conventionally, directed mechanical force over calvarium is responsible for such type
of injury. Early recognition and prompt surgical intervention in the form of wound
debridement, thorough wound wash, fracture segment reduction, removal of foreign body,
and loose bone segment with broad-spectrum antibiotic coverage is essential to prevent
morbidity and mortality and leads to better outcome.
