Effects of input energy and impactor shape on cranial fracture patterns.

This study documents relationships between input energy, impactor shape, and the formation of fractures in human crania. Parietal impact experiments (n = 12) were performed at 67% higher input energy compared to previously reported experiments. Fracture origins, characteristics, and locations were compared at two input energy levels with three impactor shapes (focal "hammer", flat "brick", and curved "bat"). Impacts with all three impactors at both energy levels produced fractures originating at and remote to the impact site, indicating both mechanisms are typical in temporoparietal blunt force impacts. Higher energy impacts generally produced more impact site fractures, depression, and comminution than lower energy impacts. A small, focal impactor produced cone cracks, depression, and fractures localized near the impact site. A broad, curved impactor produced circumferential fractures and linear fractures extending into adjacent bones. A broad, flat impactor produced fracture patterns ranging from linear fractures to large depressed and comminuted defects.

Imaging Findings in Pediatric Accessory Cranial Sutures using 3D CT Reconstruction: Fracture or Rudimentary Suture.

Objective: Although accessory sutures are considered to be relatively rare, the consequences of a missed diagnosis are profound. Distinguishing between accessory sutures and cranial fractures can be difficult, especially in cases of suspected non-accidental trauma. High-resolution imaging is the best way to discern between two- and three-dimensional computerized tomography (3D CT) is considered the preferred method for evaluation. The goal of this study was to determine the impact of 3D CT scans in distinguishing between accessory sutures and cranial fractures in suspected child abuse cases in a rural community and the importance of early detection in such cases, as well as call attention to the consequences of initial misinterpretation. Materials and methods: The researchers conducted a retrospective chart review of all pediatric patients diagnosed with cranial fractures (265 in total) at University Medical Center between May 30, 2016, and May 30, 2021. Initial computed tomography (CT) scans and subsequent 3D CT scans were evaluated for each patient that fit the inclusion criteria, 13 in total. Patients were then categorized into two groups based on the final diagnosis on the radiology report: accessory cranial suture or cranial fracture. Once these patients were identified, the etiology and structural components of each were evaluated, and the key differences were highlighted. Results: Our results showed that, of the 11 cases of suspected non-accidental trauma, six were finally diagnosed with accessory sutures with the use of 3D CT scans, and of those six, four were diagnosed with cranial fractures from the initial CT scan report due to a similar presentation and asymmetric nature. Conclusion: Discerning between fracture and accessory suture is essential in evaluating pediatric patients presenting with signs of cranial fracture due to the increased risk of misinterpretation that can lead to severe legal consequences considering that cranial suture variants may mimic intentional injury and be mistaken for child abuse, causing significant distress for patients and their families.

Reconstruction of depressed skull fracture in school patients. Technique description.

OBJECTIVE: Depressed skull fractures are the result of trauma injuries. They are present in approximately 3% of patients who arrive to an emergency room with skull trauma. The main objective of surgical repair in depressed fractures is correction of cosmetic deformity and the prevention of infections. MATERIAL AND METHODS: A retrospective and transversal study was performed by our department between April 2016 and May 2017. Sixteen patients that underwent a craniotomy for skull trauma with depressed fracture were included in the study. The diagnosis was made by simple cranial CT scan alongside a three-dimensional reconstruction. RESULTS: Of the sixteen patients included, 5 were females (31.2%) and 11 males (68.8%). Twelve of the cases were an exposed fracture. In 7 cases, the fracture was located at parietal bone; 5 were located at frontal bone and 4 at the temporal bone. The average Glasgow coma score in the sample was 13. There were no complications nor deaths. CONCLUSIONS: The remodeling and repositioning of the autologous bone graft allow an adequate cosmetic result and it also avoids the placement of implants without increasing the costs and additional risks.

OBJETIVO: las fracturas de cráneo deprimidas son el resultado de lesiones traumáticas. Se encuentran en aproximadamente el 3% de los pacientes que se presentan en salas de emergencia con traumatismo craneal. El objetivo principal de la reparación quirúrgica en fracturas deprimidas es la corrección de la deformidad cosmética y la prevención de infecciones. PACIENTES Y MÉTODOS: se realizó un estudio retrospectivo y transversal en nuestro departamento entre abril de 2016 y mayo de 2017. Se incluyeron 16 pacientes que se sometieron a una craneotomía por traumatismo craneal y fractura deprimida. El diagnóstico se realizó mediante tomografía computarizada craneal simple con reconstrucción 3D. RESULTADOS: se incluyeron 16 pacientes, 5 casos femeninos (31,2%) y 11 masculinos (68,8%). En 12 casos se observó fractura expuesta. En 7 casos la fractura se localizó en el hueso parietal; 5 casos en el hueso frontal y 4 casos en hueso temporal. El puntaje promedio en la Escala de Coma de Glasgow fue 13. No hubo complicaciones o muertes. CONCLUSIONES: la remodelación y el reposicionamiento del injerto óseo autólogo permite un resultado cosmético adecuado evitando la colocación de implantes sin aumentar los costos y riesgos adicionales.

The Repository of Antemortem Injury Response (REPAIR): an online database for skeletal injuries of known ages.

An accurate assessment of time since fracture is an essential component of abuse and death investigations; however, little evidence-based research exists on dating fractures, especially those of the cranial vault. This is primarily due to difficulties in procuring human fracture specimens of known posttraumatic survival times. The aim of this article is to introduce a new database through which limitations imposed by sample procurement may be mitigated. The Repository of Antemortem Injury Response (REPAIR) is a digitally accessible database of cranial vault fractures of known ages with extensive contextual information and visual documentation in the form of photography, radiography, and histological photomicrographs. This repository is a multifunctional tool that serves as a case submission portal for cranial fractures of known posttraumatic survival time, a sample database for research on fracture healing and rates of repair, a resource for comparative assessments of cranial fractures in forensic casework, and an educational tool for healing fracture histomorphology.

Refractory Elevated Intracranial Pressure (ICP) in the Setting of a Traumatic Cerebral Sinus Venous Thrombosis (CSVT).

The management of patients with elevated intracranial pressure (ICP) requires a systematic approach. After the failure of tier zero, tier one, and tier two therapies, all potential secondary causes of elevated ICP must be reviewed. Up to 28% of patients with blunt traumatic brain injury (TBI) develop cerebral sinus venous thrombosis (CSVT), among these, patients up to 55% have occlusive thrombi. A literature review revealed a dearth of specific treatment guidelines in this scenario. Here, we present one such case of refractory elevated ICP due to occlusive CSVT secondary to skull fractures. Initial CT venogram (CTV) on admission showed an occlusive CSVT; however, subsequent CTV on the post-trauma day (PTD) 4 and 6 showed non-occlusive thrombi only. The risks of worsening acute TBI-related hemorrhage with systemic anticoagulation versus the benefit of treating an occlusive CSVT are discussed here. In cases of occlusive CSVT with refractory elevated ICP and stable intracranial hemorrhage, the benefit of anticoagulation may outweigh the overall risks of hemorrhage expansion as prolonged uncontrolled ICP elevation is inevitably fatal. In this case, anticoagulation started on PTD 6, led to the resolution of ICP elevation and an excellent outcome for the patient, who was discharged to an acute rehab center, subsequently discharged home with no residual motor deficits, and was able to resume employment. Further prospective trials are necessary to develop guidelines for the management of occlusive CSVT in patients with severe TBI and to determine which patient populations are likely to benefit from early initiation of therapeutic anticoagulation.

A systematic approach to the interpretation of gunshot wound trauma to the cranium.

This chapter employs the fracture assessment triad, a systematic analytical approach, as a vehicle to explore the components used to interpret gunshot trauma to the cranium. First, a list of pertinent observations associated with gunshot trauma to the cranium is presented with a brief description of each. These features include entrance and exit wound defect morphology, keyhole defect, gutter defect, radiating fractures, concentric fractures, bone plugs, and associated foreign material, debris and residue. Second, the intrinsic factors that govern the way bone responds to trauma can be surmised through a direct examination or knowledge of the skeletal case. Intrinsic factors rest primarily in bone being a viscoelastic material with anisotropic properties, but include other elements that affect fracture production, such as buttressing, bone architecture, sutures, and influences of age, sex and health. These influences may be discoverable and factored into the analysis. With direct observation of the defect/fracture pattern and an understanding of the intrinsic influences involved, the extrinsic factors can be deduced. Bullet velocity, mass, design and cavitation represent the major extrinsic factors involved in wound production. The interplay of each of these factors imparts varying amounts of kinetic energy to soft and hard tissues. The greater amount of kinetic energy conveyed, the larger the temporary cavity and the greater the potential for destruction. When interpreting gunshot trauma, precision is enhanced by the analyst's familiarity with firearms and ammunition, facilitating determination of firearm type (rifle/handgun or shotgun), bullet direction, range, sequence of fire, and potentially, speculations as to bullet velocity, mass and design. Neither caliber nor gauge can be determined from the entrance defect size, but elimination of certain calibers or gauges may be possible.

Experimental investigation of cranial fracture initiation in blunt human head impacts.

The relationship between the point of blunt impact and the location of cranial fracture initiation continues to be poorly understood. The current study used high-speed video to capture cranial fracture initiation and propagation in impact experiments on twelve unembalmed, intact human cadaver heads. Video footage provided direct evidence that blunt cranial impacts can produce linear fractures initiating peripheral to the impact site. Four tests produced only remote peripheral linear fractures with no damage at the known point of impact, demonstrating that the pattern of linear fractures does not necessarily indicate impact site. The range of variation observed in these experiments suggests that cranial fracture formation is more complex than it is typically described in the current literature. Differences in biomechanical and fracture results obtained with three different shaped implements provided evidence that impact surface is one important factor influencing the outcomes of blunt cranial impacts.