TRAUMA TO THE SCALP (LACERATIONS) TRAUMA TO THE HEAD TRAUMA TO THE SCALP (LACERATIONS) 2.TRAUMA TO THE SCALP ( FRACTURES) 3.TRAUMA TO BRAIN CONTUSIONS LACERATIONS HEMORRHAGE Prof. C. E. Connolly

SCALP Because of tight appostion of the scalp to the calavrium – lacerations easily occur Bleed copiously +++ Hard to stop. There is free communication between the vessels of the scalp and face to the veins of the meninges.  Danger of Meningitis especially when the laceration is accompanied by a # of skull. There may be grave injury to the brain without skull # or scalp injury.

Fractures of the Skull 1. Localised Depressed Fracture: due to blunt force .ie. Hammer blow. Plank of wood etc. 2. Linear Fracture due to R.T.A. Blunt force or a simple fall often to the Base of skull ( easy to miss on X Ray) Note Look for bleeding from the ear(s) or into the orbit – Black Eyes- Hematuma of Eye - # Base of skull. Leak of C.S.F. from nose – Clear Fluid.

Concussion/ Loss of Consciousness Injury Instantaneous loss of function of loss of consciousness followed by rapid (mins) and complete recovery. If consciousness lost the individual experiences no sensation until his sudden rather surprised awakening. Retrograde Amnesia- No memory of blow. Duration of loss of consciousness is a guide to the degree of cerebral pathology. Pathology  Mild degrees of Diffuse Axonal Injury ( D.A.I.)

Intracranial Hemorrhage 1. Extradural: Blood between Bone and (“Epidural”) Dura. 2.Subdural: Blood between Dura and Brain. 3. Subarachnoid: Blood beneath the Leptomeninges due to a ruptured Berry Aneurysm or Trauma – RTA or Blow to side fo the upper neck ( Karate Chop!)

Extradural Clinical Trauma (Kick, Blow) to the side of the head Concussion – Rapid Recovery- Lucid interval- Loss of consciousness – coma- Death with 6-12 Hours or less! Path # of Temporal Bone (Fragile) with tearing of the middle meningeal artery/vein  Slow bleeding with gradual separation of Dura from Bone over period of 6-12 Hours . Accumulation of a large Hematoma Outside Dura Compression of Brain.

Subdural Clinical : Elderly Patient – Minor trauma (fall etc.) to head . Usually no Skull fracture. Presents a week or two later with C.N.S Deficit i.e. Memory loss, Blurred vision , Headache, Epilepsey PATHOLOGY Tearing of Veins as they enter the Sup. Saggital Sinus due to the shearing force on veins coming from a small atrophic brain which is oscillating due to minor trauma  Slow Venous Oozing into subdural space (200 – 500 mls) Granulation tissue grows into Hematoma from Dura.

Subdural Path Hematoma becomes encapsulated by granulation tissue – thin capsule formed. Hematoma may increase in volume by 1. Rebleeding from granulation tissue 2. Hyerosmotic state Hematoma may draw in CSF from subarachnoid space below 3. Further falls, trauma etc.

Extradural Hemorrhage

Head Trauma - Children Child’s skull bones are pliable. Unusual to see fractures. Usually see Ping-Pong Ball indentations ( “fractures”) in skull . Middle Meningeal Artery torn much less often. Separation of sutures often seen with violent trauma rather than a fracture. Tearing of Bridging veins from Cerebral Cortex to Sup. Saggital Sinus  Acute Subdural Hematoma. I.C.P. 

Coup Injuries When the stationary head is struck with a blunt instrument (i.e hammer) contusions are located beneath the point of impact Contusion- Pinpoint Necrosis of Brain Tissue – rupture of tiny capillaries – Bleeding resolution over weeks –months – Tiny Brown concave depression.

ContraCoup Injuries When the moving head strikes a firm surface. i.e. (Footpath, Road, etc.) Brain contusions are located opposite the point of impact in the absence of a skull fracture FALL  FALL

Contra Coup ( Mechanism) Brain Lag: As the skull is accelerated towards the ground the brain will lag towards the anterior surface compared to the CSF insulation fluid which shifts immediately in the direction of CSF Acceleration sloshs to the back. Fails to insulate brain anteriorly – Damaged against underlying rough projection bone.

Trauma to the Head 1. Blunt trauma due to blows to Head Laceration of Scalp Fractures of Skull Extra-Dural Hematoma – Contusions of Brain 2. Head-in-Motion Injury Falls, RTA’s, Boxers, etc. Subdural Hematoma (No fractures) (Tearing of veins) AND/OR Diffuse Axonal Injury (D.A.I) (Shearing of Axons) (90% due to RTA’s)

Acute Traumatic Subarchnoid Hemorrhage Cause: Trauma to the Verteral Artery with a Laceration. Artery is most vulnerable on the transverse process of C1 where it emerges from the foramina Bleeding under pressure into the subarachnoid space up. In the posterior fossa. Trauma may be due to 1. Blow to the side of the behind the Ear (Karate Chop) 2. Acute Rotational Movement to the Head

Trauma to the Brain . II Children Commonest cause of Death in Children – Intracranial Hemeorrhage + Skull Fracture Specifically Subdural Hematoma Blunt Impact ( Fist , Fall etc.) Cause  Shaking Head (“Shaking Baby Syndrome”) Death due to  Cerebral Edema ++++  Diffuse Axonal Damage Sub Dural Haem. due to rupture of vessels in subdural space.