بسم هللا الرحمن الرحيم المقابسة الجراحية الثانية كليه طب الموصل فرع الجراحه
A rare complication of linear skull fracture Presented by Hassan Qusay Ismaeel
History was taken from the mother of the patient رحيق ق. م. Name: Age: 9 months Gender: female Residency: AL-Gwiar Blood group: O+ Date of Admission: 27 th of September 2012 Date of Interference: 9 th of October 2012 Date of Examination: 11 th of October 2012
Chief complaint and duration: Swelling over the left side of forehead for two weeks following trauma
History of the present illness: Nine months old baby presented with swelling over the left side of forehead after trauma. The condition started two weeks after falling from the surface of the home which is about 3 meters from a cement made floor. The patient lost consciousness for one hour with scratches on the left side of the forehead. There was no obvious bleeding, no abnormal movement, no vomiting, no watery nasal discharge and no apparent focal weakness.
History of the present illness (continued) She was taken to hospital when she was still having disturbed level of consciousness. In the emergency department x-rays and CT were done and revealed a left frontal linear skull fracture which mandated admission of the child. She was treated conservatively. Swelling over the left side of forehead and swelling of the left eye then developed, otherwise the child was normal and under supervision.
History of the present illness (continued) In hospital, the child improved, the swelling disappeared and the patient discharged. However, few days later the swelling reappeared and the mother said it was like throbbing. The patient admitted again and over six uneventful days in hospital another CT was done and according to its results, the doctor decided to go with surgical treatment.
Review of other systems: no remarkable symptoms Past medical history: negative Past surgical history: no history of previous trauma or surgery. Drug history: no drug was being used before admission, no known allergy to specific drugs, no plaster allergy Family history: negative Socioeconomic: moderate status and father is a free worker.
General examination The child was conscious Vital signs were normal. On Examination Pupils size and response was normal and reacting to light. No lateralizing signs. No feature of basal skull fracture. No feature of facial fracture.
Local examination Head examination revealed a lump over the left side of the forehead above left eye. Size: 5*5 cm Shape: hemispherical Color of overlying skin: normal On palpation Surface: smooth Temperature: normal Tenderness: not tender Edge: defined Consistency: soft Fluctuation: +ve Composition: cystic Transillumination : +ve Pulsatility: +ve The lump is not attached to the skin and little mobile State of local tissues and regional lymph nodes were normal
Lump over the left frontal area
Neurological examination. Cranial nerves -optic is normal the child follows object. -3 rd,4 th,6 th, are normal and no gaze palsy. -7 th cranial nerve is intact and no facial palsy. -5 th,9 th,10 th, were normal. Motor system -Tone was normal. -Power : normal power symmetrical. -Reflexes was present and normal.
What is your differential diagnosis?
Growing skull fracture OR Post Traumatic Leptomeningeal cyst
Investigations Complete blood count -HB=15.1 G/dL -RBC= 6 250 000 -WBC= 17.1*10^9/L -platelet= 439*10^9/L Blood urea= 3.9mmol/L Blood sugar (random)= 6.7mmol/L Prothrombine time=13.9 sec. APTT= 33 sec.
Treatment is surgical Treatment Under GA, ETT in supine position Bicoronal skin flap done, dissection, craniotomy around the fracture line, identification of the dural tear, watertight duroplasty done using periosteum and closure in layers with a drain. Post. op. The child had low grade fever, she was irritable, analgesia and antibiotics were given. The patient passed urine at day onw, bowel motion at day two.
The dural tear
Closure of the dural tear
Before operation After operation
The diagnosis is
Growing skull fracture A rare delayed complication of linear skull fracture usually after 2-3 months. Usually parietal. Never occur after 8 years of age. In our case It was early (within 10 days). It was frontal.