Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Traumatic head injuries are a major cause of death, and disability but it
might be best to refer to the damage done as traumatic brain injury.
The purpose of the head, including the skull and face, is to protect the
brain against injury. In addition to the bony protection, the brain is covered
in tough fibrous layers called meninges and bathed in fluid that may provide a
little shock absorption.
When an injury occurs, loss of brain function can occur even without visible
damage to the head. Force applied to the head may cause the brain to be directly
injured or shaken, bouncing against the inner wall of the skull. The trauma can
potentially cause bleeding in the spaces surrounding the brain, bruise the brain
tissue, or damage the nerve connections within the brain.
Caring for the victim with a head injury begins with making certain that the ABCs
of resuscitation are addressed (airway, breathing, circulation). Many
with head injuries are multiple trauma victims and the care of their brain may
take place at the same time other injuries are stabilized and treated.
The skull is made up of many bones that form a solid container for the brain.
The face is the front part of the head and also helps protect the
brain from injury. Depending upon the location of the fracture, there may or may
not be a relationship between a fractured skull and underlying brain injury.
Of note, a fracture, break, and crack all mean the same thing, that
the integrity of the bone has been compromised. One term does not presume a more
severe injury than the others. Fractures of the skull are described based on
their location, the appearance of the fracture, and whether the bone has been
Location is important because some skull bones are thinner and more fragile
than others. For example, the temporal bone above the ear is relatively thin and
can be more easily broken than the occipital bone at the back of the skull. The middle meningeal artery is located in a groove within the temporal
bone. It is susceptible to damage and bleeding if the fracture crosses that
Basilar skull fractures occur because of blunt trauma and describe a break in
the bones at the base of the skull. These are often associated with bleeding
around the eyes (raccoon eyes) or behind the ears (Battle's sign). The fracture
line may extend into the sinuses of the face and allow bacteria from the nose
and mouth to come into contact with the brain, causing a potential infection.
In infants and young children, whose skull bones have not yet fused together,
a skull fracture may cause a diastasis fracture, in which the bone junctions
(called suture lines) widen.
Fractures can be linear (literally a line in the bone) or stellate (a starburst like pattern) and the pattern of the break is associated with the type
of force applied to the skull.
Penetrating skull fractures describe injuries caused by an object
entering the brain. This includes gunshot and stab wounds, and impaled objects
to the head.
A depressed skull fracture occurs when a piece of skull
is pushed toward the inside of the skull (think of pressing in on a ping pong
ball). Depending upon circumstances, surgery may be required to elevate the
It is important to know whether the fracture is open or closed (this
describes the condition of the skin overlying the broken bone). An open fracture
occurs when the skin is torn or lacerated over the fracture site. This
increases the risk of infection, especially with a depressed skull fracture in
which brain tissue is exposed. In a closed fracture, the skin is not damaged and continues to protect the underlying fracture from contamination from the outside world.
Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editors: Melissa Conrad Stöppler, MD
Minor head injuries are a routine occurrence. From toddlers falling against
tables, kids bumping heads playing ball, to an elderly person falling down;
people often lead with their heads when they move about. Usually, a few stars
are seen, a headache happens, and all is well. Sometimes it isn't so clear. The
person may be knocked out for a few seconds, may
vomit, and perhaps may have
some loss of memory but by the time the doctor visits the bedside, everything is
back to normal. The diagnosis of a concussion is made.
But now what? What do you do with somebody who acts and appears normal, even
though there was a history of a head injury? Who will have bleeding in their
brain and who won't? Who needs a CT scan and who just needs to go home?