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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 1  |  Page : 149-151

Compound "elevated" fracture of the cranium


Department of Neurosurgery, St. Johns Medical College Hospital, Bangalore - 560 034, India

Date of Acceptance02-Jul-2009
Date of Web Publication8-Mar-2010

Correspondence Address:
S Bhaskar
Department of Neurosurgery, St. Johns Medical College Hospital, Bangalore - 560 034
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.60421

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How to cite this article:
Bhaskar S. Compound "elevated" fracture of the cranium. Neurol India 2010;58:149-51

How to cite this URL:
Bhaskar S. Compound "elevated" fracture of the cranium. Neurol India [serial online] 2010 [cited 2019 Aug 23];58:149-51. Available from: http://www.neurologyindia.com/text.asp?2010/58/1/149/60421


Sir,

Skull fractures are classified based on pattern (linear, diastatic, comminuted, depressed), by anatomic location (convexity, basal) and by type (simple, compound). [1],[2] There is significant morbidity and mortality associated with the compound depressed fractures. [3] Even though there is a theoretical possibility of a fracture segment being elevated, it finds very few references in neurosurgical literature. [4],[5],[6] The largest number of cases reported together being four [Table 1]. [6] Here, we present a patient with compound elevated fracture involving the vault is presented.

A 19-year-old man was referred to the neurosurgical unit with a deep cut over the left temporo-parietal region. He had injured himself when he fell off the motorcycle while riding as a pillion rider. He did not lose consciousness after the fall. He was taken to a hospital where the scalp laceration was sutured and subsequently referred to our centre. He reached the Emergency Department 6 hours after the trauma. At presentation to our centre, the vitals were stable, and GCS was 13/15 (E3V4M6) without focal limb deficits. He had a 10 cm long lacerated wound over the left temporo-parietal region. He also had a fracture of the left clavicle, few broken teeth but no systemic injuries.

Computed tomogram of the head revealed a left temporo-parietal compound fracture with underlying extradural haematoma and the fracture segment was elevated above the surrounding normal bone [Figure 1] a-d. He underwent surgery during which wound debridement, evacuation of extradural haematoma and replacement of bone flap was done. The fracture fragment was floating above the bone and was only attached by the temporalis muscle origin. There was no dural tear. Following surgery, the patient made an uneventful recovery and the wound healed well. He was discharged after 10 days with no focal deficits. Presently, he is asymptomatic 6 months after surgery.

The impact causing a vault fracture generally drives the bone fragment inwards and thus leads to a depressed fracture. There have been instances reported where the fragment has been elevated above the level of the normal bone. The mechanisms proposed for this are the lateral pull of the object or rotation of the head at the time of impact, as happens in injuries sustained with a long, sharp object such as propeller or machete. [6],[7] Another mechanism might be elevation of the free fragment while attempts are made to remove the offending object or while the patient is transferred. [6] The mechanism in this case was probably the free fragment of the bone and the underlying extradural haematoma. Elevated fractures are always compound as has been reported earlier. [4],[5] Dural breach is often present but there have been cases where the dura was intact. [7] These should be managed as compound depressed fractures. There are instances where the bone segment is completely avulsed, resembling a craniotomy. [8] Early recognition and treatment of this type of fracture would reduce the morbidity and mortality and improve outcome. As seen in this case, elevated fractures can occur when there is a circular piece of fractured bone with an underlying lesion (e.g. haematoma).

 
  References Top

1.Geisler FH. Skull fractures. In: Wilkins RH, Rengachary SS, editor. Neurosurgery. New York: McGraw-Hill; 1996. p. 2741-54.  Back to cited text no. 1      
2.Kaye AH. Head injury. In: Kaye AH, editor. Essential neurosurgery. Singapore: Churchill Livingstone; 1991. p. 59-80.  Back to cited text no. 2      
3.Cooper PR. Skull fracture and traumatic cerebrospinal fluid fistula. In: Cooper PR, editor. Head injury. Baltimore: Williams and Wilkins; 1993. p. 115-36.  Back to cited text no. 3      
4.Ralston BL. Compound elevated fractures of the skull. Report of two cases. J Neurosurgery 1976;44:77-8.  Back to cited text no. 4      
5.Verdura J, White RJ. Compound elevated skull fractures. J Neurosurg 1976;45:245.  Back to cited text no. 5      
6.Adeolu AA, Shokunbi MT, Malomo AO, Komolafe EO, Olateju SO, Amusa YB. Compound elevated skull fracture: a forgotten type of skull fracture. Surg Neurol 2006;65:503-5.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Borkar SA, Sinha S, Sharma BS. Post Traumatic compound elevated fracture of skull simulating a formal craniotomy. Turkish Neurosurg 2009;19:103-5.  Back to cited text no. 7      
8.Aniruddha TJ, Indira Devi B, Arivazhagan A. Traumatic avulsion of cranial bone flap simulating craniotomy. Indian J Neurotrauma 2008;5:53.  Back to cited text no. 8      


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