Surgical Neurolog

Trauma

Compound elevated skull fracture: a forgotten type of skull fracture

Augustine Abiodun Adeolua,T,1, Matthew Temitayo Shokunbib, Adefolarin Obanisola Malomob,

Edward Oluwole Komolafea,1, Samuel Oluremi Olatejua, Yemisi Bola Amusaa

aDepartment of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria 20001bDepartment of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria

Received 29 June 2005; accepted 6 July 2005

Abstract Background and Objective: We report 4 patients who presented with a rare type of vault fracture.

www.surgicalneurology-online.com

0090-3019/$ – see fro

doi:10.1016/j.surneu.2

Abbreviations: CS

GCS, Glasgow Coma

T Corresponding

E-mail address: a1 Previously at De

of Ibadan, Ibadan, Ni

This form of fracture has only been described in few instances in the literature.

Case Description: All the patients presented with elevation of free skull fracture fragments. The

etiologies were assault (1 patient), domestic accident (1 patient), and road traffic accident (2 patients).

All the fractures were compound as in previously reported cases. Delay in surgery resulted in

cerebral abscess in 1 patient. Surgery was performed in all the patients: wound debrident, duroplasty,

and reduction of fracture in 3 patients and craniotomy with excision of abscess in 1 patient. Two of

the patients did well after surgery. The patients with abscess died 9 days after surgery. Another

patient developed CSF fistula after surgery, and died of aspiration while waiting for the closure of

the fistula.

Conclusion: Elevated skull fractures in our series were all compound fractures. Both long, sharp

objects as well as blunt objects can cause this injury. Delay in surgery could result in intracranial

sepsis. We suggest that this fracture should be included in the classification of skull fractures.

D 2006 Elsevier Inc. All rights reserved.

Keywords: Skull; Fractures; Elevated; Compound; Duroplasty

1. Introduction

Skull fractures are traditionally classified into linear,

comminuted, or depressed [1-4]. A depressed fracture by

definition is any fracture with an in-driven fracture

fragment. Any of these can be simple (closed) or compound

(open). Theoretically, it should be possible to have skull

fracture with a fragment elevated above the level of the

intact skull bone. This is rarely mentioned in neurosurgical

texts, and clinical evidence of this fracture type has only

been highlighted in the literature in few instances [5,6]. We

present 4 cases to further illustrate this rare form of skull

nt matter D 2006 Elsevier Inc. All rights reserved.

005.07.010

F, Cerebrospinal fistula; CT, Computed tomography;

Score.

author. Tel.: +234 8032477341.

deoluaa@yahoo.com (A.A. Adeolu).

partment of Surgery, College of Medicine, University

geria.

fractures and to call for the inclusion of the fracture in the

subtypes of skull fractures.

2. Case Report

2.1. Case 1

A 30-year-old man was referred to our unit with a deep

machete cut over the left frontoparietal region. He sustained

the injury during a communal clash about 4 weeks before

presentation and had lost consciousness for a few hours. At

presentation, he was awake and alert. He also had expressive

aphasia and had right hemiparesis, although he was ambulat-

ing without support. He had a deep left frontoparietal

laceration about 20 cm in length. The wound was gaping

and contained exuberant granulating tissue. His cranial CT

showed fracture involving the left frontoparietal bone with

elevation of the upper bone flap (Fig. 1A and B). There was

atrophy of the underlying brain. The patient subsequently

had wound debridement, duroplasty with facia lata graft,

y 65 (2006) 503–505

A.A. Adeolu et al. / Surgical Neurology 65 (2006) 503–505504

and replacement (depression) of the elevated fragment. He

did well after surgery with improvement in his neuro-

logic deficits.

2.2. Case 2

A 34-year old female patient presented to the accident and

emergency services 3 days after a road traffic accident. She

was a back seat passenger in a saloon car that collided with a

stationary car. She lost consciousness immediately. At

presentation, her GCS was 12 of 15. The pupil on the right

was 5 mm in size and unreactive, the left was 3 mm and

reacted briskly to light. She had a sutured laceration over the

right fronto-orbital region. She also had bilateral raccoon

eyes with conjunctival hemorrhage. The cranial CT at this

time showed elevated right frontotemporal fracture, ethmoi-

Fig. 1. A: Cranial CT of case 1 showing fracture of the temporoparietal

bone with elevation of the fracture fragment. There is atrophy of the

underlying brain tissue. B: Cranial CT of the same patient as A with bone

window. The elevated left frontoparietal fracture is well depicted.

Fig. 2. Contrast-enhanced CT scan of case 2. There is elevation of the

fracture fragment involving the right frontoparietal bone. There is a hypo-

dense lesion in the right frontal lobe. The lesion enhances brilliantly with

contrast peripherally. It was confirmed to be cerebral abscess at surgery.

dal complex fracture, comminuted fracture of the anterior

wall of the right maxillary sinus, and multiple hemorrhagic

contusions involving the right frontal lobe. She also had

multiple long bone fractures. She was scheduled for wound

debridement, reduction, and fusion of the fractures. While

waiting for surgery, her GCS improved to 14 of 15. Twenty

days after admission, her GCS decreased to 11 of 15. A

repeat cranial CT showed huge right frontal lobe hypodense

lesion with peripheral contrast enhancement, which was

thought to be cerebral abscess (Fig. 2). She subsequently had

right frontal craniotomy and excision of the abscess cavity.

There was an immediate postoperative improvement from

GCS 9 to 13, but the patient died 9 days after surgery from

septicemia and septicemic shock.

2.3. Case 3

An 8-year old female patient presented to the children

emergency unit with history of fall. She fell off a stationary

motorcycle 12 hours before presentation. The pedal of the

motorcycle penetrated her skull through the left parietal

region, and she lost consciousness immediately. Her GCS at

presentation was 12 of 15. She had right hemiparesis and a

laceration of about 5 cm over the left parietal region. Her

skull x-ray showed fracture of the left parietal bone with the

free fragment displaced outwardly (Fig. 3). A cranial CT

was requested but the patient could not afford it. She had

debridement, reduction of the fracture (depression), and

duroplasty. She was initially doing well but developed CSF

leakage 4 days post operation. Patient was rescheduled for

reoperation but aspirated and died before this could

be performed.

2.4. Case 4

AO was a 35-year old male patient who presented to our

emergency department 6 hours after a pedestrian motor

Fig. 3. Lateral skull x-ray of case 3. There is occipitoparietal soft tissue

swelling. The tip of the pen is pointing to the elevated bone fragment. There

is associated bony defect immediately beneath the elevated bone.

A.A. Adeolu et al. / Surgical Neurology 65 (2006) 503–505 505

vehicular accident. He sustained extensive laceration of

the forehead due to contact with the panel of the vehicle.

His GCS at presentation was 8 of 15. The right pupil was

fixed and dilated. The left pupil was 3 mm and reactive. He

also had left hemiparesis and about a 15 cm laceration

extending from the bridge of the nose to midway to the

vertex. Brain tissue was seen herniating through the

laceration. There were free bone fragments elevated above

the intact left frontal bone. Cranial CT and skull x-rays

could not be done because the machines were not

functional when the patient presented. He subsequently

had wound debridement, reduction of the fracture (depres-

sion), duroplasty, and reconstruction of the anterior cranial

fossa with facia lata, as well as exenteration of the frontal

sinuses. In addition to the findings above, comminuted

fractures of the anterior cranial fossa, including the frontal

sinuses and right orbital roof and optic canal, were

discovered during surgery. Patient’s sensorium improved

thereafter. He developed CSF rhinorrhoea 6 days post

operation, which responded to CSF drainage using

lumber catheter. Patient is still being followed up in the

outpatient clinic.

3. Discussion

The agent of wounding in vault fracture is often directed

inwards and, as such, in any injury with a floating fracture

fragment, the inward direction of the applied force drives the

fragment intracranially. This will result in depressed

fracture. In some peculiar cases, a long, sharp wounding

object such as machete or propeller elevates the fracture

fragment by a lateral pull of the object or rotation of the

head. This was the mechanism in previously reported cases

[5]. Cases 1 and 4 (see Fig. 1) in our series fit into this

category. The scalp wound in this situation is often long. In

our series, one of the patients sustained the fracture from a

penetrating injury (case 3 and Fig. 3). The mechanism of

elevation in this instance is not certain. It may be from

displacement of the free fragment during retrieval of the

agent of wounding or transfer of the patient.

Elevated fractures are always compound as earlier

reported [5,6]. The dura is also often turned and we advocate

that these injuries should be managed as open depressed

skull fracture. Delay or failure to operate may be complicated

by intracranial sepsis as exemplified by case 3.

We suggest that this group of fractures should be

included in the classification of skull fractures. Early

recognition and appropriate management will prevent

unnecessary morbidity and mortality.

References

[1] Cooper PR. Skull fracture and traumatic cerebrospinal fluid fistula. In:

Cooper PR, editor. Head injury. Baltimore7 Williams and Wilkins;

1993. p. 115-36.

[2] Geisler FH, Manson PN. Traumatic skull and facial fracture. In:

Rengachary SS, Wilkins RH, editors. Principle of neurosurgery.

Philadelphia: Mosby-Wolfe; 1994. p. 18.2-18.31.

[3] Geisler FH. Skull fractures. In: Wilkins RH, Rengachary SS, editors.

Neurosurgery. New York7 McGraw-Hill; 1996. p. 2741-54.

[4] Kaye AH. Head injury. In: Kaye AH, editor. Essential neurosurgery.

Singapore7 Churchill Livingstone; 1991. p. 59-80.

[5] Ralston BL. Compound elevated fractures of the skull. Report of two

cases. J Neurosurgery 1976;44:77 -8.

[6] Verdura J, White RJ. Compound elevated skull fractures. J Neurosur-

gery 1976;45:245.