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CASE 7.1 SKULL FRACTURE

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Patient Presentation

An 18-year-old male was brought to the emergency department after he was found unconscious on the ski slope. His friends told the ski patrol that while they were "boarding" on a difficult run he lost control and collided with a tree.

Relevant Clinical Findings History

On the way to the hospital, the patient regained consciousness. When he arrived in the emergency department, he appeared dazed and complained of headache. He responded appropriately to questions (e.g., he knew time, date, and place) and confirmed that he lost control while skiing and "crashed" into a tree.

Physical Examination

Noteworthy vital signs include:

  • Blood pressure: 120/80 mm Hg (normal adult: 120/80)

  • Pulse: 75 bpm (adult resting rate: 60–100 bpm)

  • Respiratory rate: 17 cycles/min (normal adult: 14–18 cycles/min; women slightly higher)

Noteworthy results of physical examination:

  • Facial abrasions

  • Swelling above the right ear

Noteworthy results of neurologic examination:

  • Pupils were equal, round, and reactive to light (PERRL)

  • Normal extraocular movements

  • Numbness on right side of face

Imaging Studies
  • Radiography upon admission to the emergency department confirmed a small, lateral skull fracture.

  • Computed tomography (CT) revealed a hyperdense, biconvex (lens-shaped) mass between the brain and the skull.

The patient was kept for observation in the emergency department. Several hours later, the patient lost consciousness and his right pupil was dilated. He became bradycardic, hypertensive, with a decreased respiratory rate.

Clinical Problems to Consider

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LEARNING OBJECTIVES

  1. Describe the anatomy of the lateral skull.

  2. Describe the anatomy of the cranial meninges and associated spaces.

  3. Describe the anatomy of the dural folds and venous sinuses.

  4. Explain the anatomical basis for the signs and symptoms associated with this case.

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RELEVANT ANATOMY

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Lateral Skull
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The skull, or cranium, forms the skeleton of the head (Table 7.1.1). It is divided into two parts:

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Table Graphic Jump Location
Table 7.1.1Bones associated with neurocranium and viscerocranium.
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  1. The neurocranium is composed of eight "flat" bones that enclose and protect the brain.

  2. The viscerocranium, or facial skeleton, is composed of 15 irregular bones that form the mouth, nose and nasal cavities, and most of the orbits.

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The mandible is the only movable bone of the skull. All other bones articulate with each other at immovable joints known as sutures.

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The lateral aspect of the skull is formed by parts of the neurocranium and viscerocranium (Fig. 7.1.1). The parietal bone and the squamous part of the temporal bone form the ...

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