Timely diagnosis of fractures of the base of the skull with the onset of the warm season becomes even more urgent task in connection with the increase in traffic, especially motorcyclists, resulting in faster road accidents. Also at this time, the criminogenic stratum of society is activated, and as a result, the number of “street” injuries and injuries resulting from terrorist acts is increasing. Craniocerebral injuries are often found in victims during natural and man-made disasters.
The content of the article
Diagnosis of fractures of the base of the skull When entering, especially in large numbers, patients with craniocerebral trauma, it is necessary to take into account when planning the tactics of their examination and treatment such basic factors as:
- severity of the condition;
- examination data by surgeon;
- neurological symptoms;
- mechanism of injury.
Priority and method of examination
The order, volume and methods of examination are determined by the severity of the patient’s condition. At mass receipts the medical sorting is obligatory.
Patients in serious condition
First of all, the examination is carried out by seriously ill patients, people in a coma or confused consciousness, in motor excitement. In the latter case, it is advisable for intravenous injection of 10-15 ml of 0.5% novocaine 10-15 minutes before X-rays.
Radiography is performed only in the minimum necessary volume, that is, the frontal + lateral craniograms. In this case, you can not sharply turn the patient’s head, and for correct projection, you need to move the X-ray tube and cassette. In this case, a mobile (ward) X-ray apparatus is often used, in which the use of screening screens is not provided, which results in a lower quality of the images than in stationary devices.
Patients with traumas of mild to moderate severity
Secondly, patients with craniocerebral traumas of moderate to mild severity are examined and, preferably, immediately on a stationary X-ray apparatus, using screening grids (rasters). If possible, in addition to the obligatory 2 review craniograms, it is desirable to perform additional pictures in special projections (depending on the symptomatology) for more accurate localization of the fracture line and, consequently, to identify possible damage to cranial nerves, vessels and other structures.
At the end of the “emergency” schedule of the emergency department, the patients of the first stage should carry out additional studies in the special X-ray apparatus in special projections (orbits, temporal bones, temporomandibular joint, paranasal sinuses, axial and semi-axial projections) to determine the localization of the fracture line, the first three of them necessarily in pairs (for contralateral zones) with the same modes of operation of the X-ray apparatus and manifestation.
The course of the fracture of the base of the skull
In general, the course of the fracture line along the base of the skull can be represented in the same way as it would be if it struck the corresponding edge of a hemispherical porcelain cup. The most typical are the following options:
The location of the injuring force of the fracture line. The line of the fracture of the branch. Along the longitudinal axis of the base of the skull, with possible branches to the large occipital opening. The diagonal of the diagonal from front to back with possible intersection of the hypophyseal fossa. Along the borders of the middle cranium, with a high probability of forming a closed oval elongated transversely to the nose and under the base of the nose. Damage to the anterior cranial pit, bone in combination with the fractures of the upper jaw by Le Fort-2, -3Padenie from height to elongated legs A closed ring of the fracture line around the large occipital foramen with the possible introduction of this bone segment into the structures of the brain. An X-ray lining table for the diagnosis of fractures in the base of the skull
A significant help in determining the tactics of the study may be provided by the following summary table of x-ray patterns for the diagnosis of fractures of the base of the skull:
Symptomatic damage to the cranial pitPrevious damage to a pair of cranial nerves. X-ray packing. Of the nose: bleeding, liquorrhea, the emergence of cerebral detritus; hemorrhages under the conjunctiva of the eye, protrusion and displacement of the eye, subcutaneous emphysema of the orbits and eyelids, impaired sense of smell, euphoria, inadequacy of behavior, decreased sensitivity in the region of the eyebrow; front1-ocular craniograms, anterior semi-axial, axial, according to the Ear suture: bleeding, liquorrhea, cerebral detritus; vomiting of blood, emphysema of the mastoid process, restriction of opening of the mouth, blindness or (more often) loss of vision for 1 eye, ptosis of the upper eyelid, diplopia, facial asymmetry, diencephalic disorders, hearing loss in both or (more often) in one ear. 6-Obligatory craniograms, temporomandibular joint, according to Schueller,
In case of claims about the possible exceeding of the basic dose limits for the patient due to the implementation of a whole series of X-ray films “NRB-99” and “SanPiN-99” in paragraphs 3.1.3. and 9.10. give an explanation: “the limits of radiation doses for patients with DIAGNOSTIC purposes are not established,” but the X-ray laboratory technician must always, even with a massive admission of patients, apply a set of measures aimed at reducing the radiation burden on patients and staff.
Clinical symptoms of fracture of the base of the skull
Isolated fractures of the base of the skull are less common than those combined with fractures of the arch or with extended linear ones from the arch to the base of the skull and pyramids of temporal bones.
Violation of the integrity of the meninges manifests cerebrospinal fluid from the nose or ears, penetration of air into the cavity of the skull (pneumatoceles) in the form of a clear contour clarification from a plane air bubble.
In addition to the listed clinical symptoms, there may be other changes in craniograms:
Localization Characteristics of the anterior cranial pit Vertical fractures of the frontal bone, passing to the base of the skull, damage to the upper wall of the orbit, darkening of the frontal sinuses due to hemosyne, and in the projection of the Phese – damage to the walls of the optic nerve. Interiors of the middle cranial pit. Crossing the fracture of the pyramid of the temporal bone, . With a more forward location, the fracture of the temporomandibular joint can be damaged. On special layings of the temporal bones (according to Schueller, Mayer and Stenvers), one can see that the fissures reach the middle ear structures, damaging the cavern wall. Peripherals of the posterior cranial fossa. The occipital bone is transferred to the pyramid of the temporal bone with the formation of a transverse fracture of the latter.
Of course, if the skull base structures are damaged, the use of conventional and computed tomography, MRI, is desirable, but this is unrealistic under normal operating conditions, especially in the CRH.
The role of the material and technical base of the laboratory and the level of preparation of X-ray laboratory technicians
A material role in the detection of bone destruction is the material and technical base of the cabinet of radiation diagnostics and the level of preparation of X-ray labors:
- old, worked for many years, dirty or scratched reinforcing cassette screens will not allow you to see even gross changes in the bones of the skull;
- small kvolovolazh or insufficient exposure (a little mA-sec) will not be able to “break” sufficiently the bone structure, whereas overexposure (many mA-sec) will not allow the termination of the manifestation in time, and then the enlightenment image in the course of the fracture line will quickly merge with the common background bone structures;
- inexperienced X-ray lab, performing special laying of temporal bones (and others performed only in pairs), if it does not achieve the identity of both images, then the doctor will not be able to differentiate the fracture of the structures of the middle ear, visual channel or temporomandibular joint;
- the absence of a drying cabinet can cause a “loss” of image details among the messy strips and spots-traces of streaks of rinsing water residues. In extreme cases, a hairdresser’s hair dryer can be used here: drying takes place quickly and efficiently, without streaks – after all, during the last 10 years, when analyzing the annual reports of X-ray rooms in the Omsk Region, the phrase “acute is the problem of drying cabinets shortage”.
To avoid overdiagnosis, the radiologist should remember that a number of normal anatomical structures are capable of simulating fractures of the base of the skull. They can be:
- furrows of branches of the middle shell artery;
- grooves of the parietal-cuneiform sinus;
- channels of diploid veins;
- the neuralgia of the wedge-occipital synchondrosis behind the back of the pituitary fossa;
- occipital mastoid seam.
In order to avoid such incidents, radiologists and surgeons should more often and more closely examine the craniograms with the known absence of pathology of the skull base, and then somewhere in the subconsciousness an image of a kind of “normal pattern” will form, thanks to which the presence of any pathology on the craniogram will provoke a discomfort signal that causes the doctor not to calm down until he discovers the factor that prevents him from writing to write: “There are no pathological changes.”
Complications of traumatic brain injury
As the main complications of craniocerebral trauma, interstitial and alveolar pulmonary edema with the development of atelectasis can already be observed in the first day, and pneumonia in the second or third day. After a few weeks, especially with concomitant fractures of the cranial vault, there may be brain abscesses, signs of osteomyelitis in the fracture zone. 2-3 months after the moment of trauma signs of adhesive processes begin to be determined due to tissue damage, infection from the cavities of the paranasal sinuses, middle ear, and computer tomograms will detect signs of deformation of the lateral ventricles of the brain with an increase in their volume on the side of the injury, a violation of liquorodynamics. Many years after the trauma, areas of decalcification of bone tissue may appear in its zone due to multiple micro-fractures.
- Lectures of prof. I.A. Gilyazutdinov in the GIDUV in Kazan (1992).
- Lectures on medicine of disasters in GIDUV Kazan (1992)
- Kishkovsky A., Tyurin L. “Emergency X-ray diagnostics”, Moscow, 1989.
- Lagunova I. “X-ray ananatomy of the skeleton”, Moscow, 1981.
- Kishkovsky A, Tyunin L «Medical X-ray technology», L, 1983.
- Yakovets V. “Manual for X-ray labors” St. Petersburg, 1993.
- Krylov I. “Criminalistics” L, 1976.
- Zedgenidze G., Zharkov P. “Mechanical damage to bones and joints” – M., 1984.
- Suslova O. “Roentgenodiagnosis of injuries and diseases of the musculoskeletal system” Kiev, 1989.
- Norms of radiation safety “NRB-99” (SP 18.104.22.1688-99).
- Corp. Microsoft. MS-DOS – user’s manual. – 1998.