UNIT 2: TRAUMATOLOGY

SUBUNIT 2.2.
TRAUMA
CONDITIONS
(C ) HEAD INJURY
OBJECTIVES
1. Outline the causes of head injury
2. Classify head injury
3. Describe the clinical features
4. Outline the management of head injury
5. Describe the indications for admission,
skull x-rays and CT scanning
6. Use the Glasgow Coma scale in assessing
severe head injury
1.CAUSES OF HEAD
INJURY
The most serious head injuries result from: -
• Road traffic accidents
• Falls from heights
• Assaults
Less severe accidents occur: -
• in the homes
• at work
• in the sports field
2. CLASSIFICATION OF
HEAD INJURIES
The most convenient classification is: -
1. SCALP INJURY
2. SKULL INJURY (SKULL FRACTURE)
(a) Vault of skull
(b) Base of skull
3. BRAIN DAMAGE
(a) Concussion
(b) Contusion and laceration
(c ) Compression
4. TRAUMATIC INTRACRANIAL HAEMORRHAGE
 The resultant injuries to the Scalp, Skull and Brain
vary in their severity
3. CLINICAL FEATURES OF
HEAD INJURY AND
MANAGEMENT
1. SCALP WOUNDS
 These could be due to incised or blunt
trauma
 CLINICAL FEATURES
 Lacerations
 Contusions
 Bleeding, this is the prominent feature
 Infection, which may spread into the
skull via veins
MANAGEMENT
Underlying bone examination for
presence of fractures
Removal of foreign bodies
Thoroughly cleansing of the wound
Debridement of the wound
The wounds sutured with full thickness
2. SKULL FRACTURES
Skull fracture may involve: -
the vault of the skull
the base of the skull which is the most

common
both the vault or the base
 The degree of fracture bears little relationship to the
severity of cerebral damage i.e.
• there could be a small fracture with severe
cerebral damage
These fractures may be: -
 Simple Fractures
 Linear fractures
linear fractures may run across the suture
lines and pass down to the base
 Comminuted fractures
depression of bone fragments is common

in comminuted fractures
 Fractures of the base of the skull
 Compounded fractures i.e. Open fractures
These may be associated with: -
linearfracture
comminuted fracture
depressed fracture
CLINICAL FEATURES
 FRACTURS OF THE BASE OF
SKULL
 Nasal, Ear bleeding
 Leakage of cerebral spinal fluid (CSF)
from the nose
 Sub-conjunctival bleeding
• usually spread over the eye from behind

• “direct haematoma has a posterior limit”

 CRANIAL NERVE INJURY
Olfactory Nerve Damage
This will lead to Anosmia(loss of sense of
smell)
Direct Trauma to the Facial Nerve
This may lead to: -

o facial palsy

o bleeding into facial canal

 Auditory Nerve Damage
• This may lead to deafness
 Increasing Pressure on the Tentorium
• tentorium lies between the cerebrum and
the cerebellum
• the increasing pressure may lead to
oculomotor paresis
TREATMENT
 Linear Fractures may not necessarily
require treatment
if there is cerebral damage attention

should be directed to that aspect

 Simple Depressed Fractures
these will require elevation

the elevation will prevent the

development of focal epileptiform

attacks
 Compound Depressed Fractures
These will require:-
 debridement then
elevation of depressed fragments
 Cerebrospinal Rhinorrhoea
This will necessitate antibiotics to lessen
risk of infection
(3) BRAIN DAMAGE
(a) CONCUSSION(sudden blow to the head /diffuse wide
spread homogeneous impairment of brain tssue)
 This is a temporary effect of Mild Head
Injury
 It is associated with a period of Amnesia
 Duration of Post Traumatic Amnesia (loss
of memory) is very important in
determining severity of brain damage
 Post traumatic amnesia duration as a guide to severity:
-
o Up to one hour – MILD
o One to 24 hours – MODERATE
o Over 24 hours – SEVERE
(b) CONTUSSION (brusing,usually of the suface of the brain
with infarction of brain parenchyma and extra vasation of
blood but without rupture of pia-arachnoid)AND
LACERATION WITH COMPREHENSION
This is a more serious injury resulting from: -
Direct trauma associated with;
o fractures of the skull

o disruption of the brain due to rapid

movement in relation to the skull

 Most severe injuries occur from sudden deceleration of
the skull in falls or motor vehicle accidents
 Haemorrhage from torn vessels may cause :-
• direct cerebral disruption or
• compression by accumulation of blood clot
 Oedema of the damaged brain produces further
compression
CLINICAL FEATURES
Attention should be paid to: -
 Level of consciousness
 Signs of paralysis of cranial nerves

 Spasticity or paralysis of limbs

 State of reflexes
 Development of bradycardia is a late sign of Cerebral
compression
 Stertorous respiration is indicative of severe damage to
the brain stem
 Examination and Observation of the Pupils: -
 Intracranial haemorrhage
there is originally equal pupils and later

unilateral dilatation
 Very extensive Damage
this will be indicated by bilateral fixed

and dilated pupils soon after injury

 Damage to the Eye or Optic Nerve
there is unilateral dilatation of the pupil at
the time of injury
 Cerebral Oedema
this will be indicated by restlessness and
photophobia
TREATMENT
 ACUTE SUBDURAL HAEMATOMA
 This brain damage requires immediate
treatment
 It is managed by BURR HOLE
decompression
 Other brain injuries require more conservative
management
• neurosurgery usually does not improve the outcome
 These conditions include: -
• Basal Skull fracture
• Cerebral Concussion
• Depressed skull fracture without severe compression
CONSERVATIVE MANAGEMENT
 Conservative management involves: -
• Stabilizing the ABC

• Immobilizing the cervical spine if

possible
• Monitoring vital signs

o these are important indicators in the

patient’s neurological status

• Use of Glasgow Coma Scale (GCS)
o this
helps in monitoring the general
status of the patient
4.CRITERIA FOR ADMISSION, X-
RAYS AND CT SCANNING FOR HEAD
INJURY
ADMISSION TO HOSPITAL
Patients requiring admission are those
who : -
are not fully conscious or oriented

present with focal neurological symptoms

or signs
have clinical evidence of fracture of base

of skull, compounded vault fracture or

penetrating injury
have radiological evidence of skull fracture
are epileptic
pose difficulties with clinical assessment
are infants
are paediatric and suspected to have been abused
have associated serious injuries or medical conditions
 • have severe increasing headache or
• are persistently vomiting
 Other patients that may require admission are those
that have no responsible observer
SKULL RADIOGRAPHS
Loss of consciousness or amnesia at any
time
Presence of neurological symptoms
Significant scalp swelling or laceration
Epilepsy
 Signs of basal skull fracture e.g.
• blood or CSF leakage from the nose or
ears
• peri-orbital haematoma
• mastoid haematoma
• haematotympanum
CT SCANNING
 Coma persisting after resuscitation
 Skull fractures in association with: -
• confusion, reduced conscious level,
• neurological symptoms and signs or
epilepsy
 Deteriorating conscious level
 Inequality of pupil dilatation
 Development of limb weakness
 Confusion persisting beyond 12 hours
5. USING A GLASGOW
COMA SCALE
EYE OPENING
 Spontaneous 4
 To speech 3
 To pain 2
 None 1
MOTOR RESPONSE
Obeys commands 6
Localized pain 5
Withdraws from pain 4
Abnormal flexion to pain 3
Extension to pain 2
None 1
VERBAL RESPONSE
Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensive sounds 2
None 1
CATEGORISATION OF SEVERITY USING GCS
 SEVERE HEAD INJURY
GCS OF 8 or less
 MODERATE HEAD INJURY
GCS between 9 and 12

 MILD HEAD INJURY

GCS between 13 and 15