290 MEDICAL BULLETIN

complicated procedures of our days which offer the schen Gesellschaft fur Chirurgie vom 25. - 28. patient no better results. Finally, no bridges are April 1962. burned for other procedures. 3. Nyakas, A.: Zur operativen Behandlung der Arth- rosis deformans des Huiftgelenks, Sonderdruck aus ~REFEREKNCE^~S ^dem Zentralblatt fur Chirurgie, Heft 9, 85. Jahr- 1. Voss, Claus: Koxarthrose - Die "temporare Hinge- gang, 1960. hiufte", Sonderdruck der Miinchner Medizinische 4. Blount, Walter: Don'tthrow away the cane, Journal Wochenschrift, Nr. 28 (Seite 954 - 956), 98. Jahrgang of Bone and Joint Surgery, American Volume, Vol. 1956; and personal communications. 38-A, No. 3, pp. 695-708, June 1956. 2. Kuentscher, Gerhard: 5. Mensor, Merrill, San Francisco: a. Die Voss'sche Operation - Die Befreiung vom Hiiftschmerz, Sonderabdruck aus Heft 3, Chirur- 6. Dehne, Colonel, Brooke Army Personal gische Praxis, 1958. Medical Center: communication b. Die Behandlung der Coxarthrose nach Voss, 7. Bertele, George, Ulm, Germany: Sonderdruck aus "Langenbecks Archiv und 8. O'Malley, A. G.: Osteoarthritis of the hip, Journal Deutsche Zeitschrift fur Chirurgie", Band 301 of Bone and Joint Surgery, British Volume, Vol. (1962), Sitzungsbericht der 79. Tagung der Deut- 41-B, No. 4, pp. 888-889.

HEAD INJURIES: An Outline of Diagnosis and Early Treatment* Major William M. Hammon, MC*

This r6sum6 of the initial evaluation necessary for the management of the sus- pected or known head-injured patient is written not as a dogmatic set of "do's" and "don'ts," but as a general guide for logical inteligent care.

DEFINITION: A head-injured person is anyone who tures and is due to marked intracranial shearing forces. has sustained trauma to the head in either a direct There is evidence of significant neurologic damage. or in indirect manner. The head includes the face but Cerebral contusions and lacerations must be admitted specific reference in this article is made to the cranium and watched very closely for progression of localizing and the intra-cranial contents. symptoms or signs of increasing intra-cranial pressure. The latter usually consist of an increasing blood pres- I. DIRECT TRAUMA; SIMPLE AND COMPOUND. sure, increasing pulse pressure, decreasing pulse rate A. Simple injuries. and respiratory irregularities. Developing pupillary T i inequality should also be looked for. When these are Definition: This is an injury which does not in- present, prompt neurosurgical attention is needed. clude a local break in the skin (i.e. scalp through the galea). 2. The Hematomas. 1. Cerebral involvement without a hematoma mass a. . lession. This is a blood clot formed in the space between the a. Cerebral . inner table of the skull and the dura mater, usually secondary to a tear of the Middle Meningeal Artery This is a temporary loss of consciousness lasting up and le commonly due to venous bleeding from the to a few minutes without localizing cerebral findings, fracture site or a torn bridging vein. It is generally a good policy to admit these patients for at least overnight observation at the local dispen- The accepted typical history is of head trauma sary or hospital level. Children may be sent home for with or without a variable period of unconsciousness close observation by reliable parents who live near followed by a period of several minutes to several the medical facility. If the child is unusually drowsy hours of improvement (the "lucid" interval), then rapid or has vomited it is advisable to admit as above. deterioration with hemiplegia, a dilated fixed pupil, vital sign changes due to increasing intra-cranial pres- b. Cerebral contusions. sure and death due to brain stem compression. This is a "bruised brain" and involves a longer period requires immediate surgical interven- of unconsciousness and/or localizing cerebral findings tion at the local hospital to evacuate the hematoma than is found with a cerebral concussion. and prevent its recurrence. Evacuation to a neuro- c. Cerebral laceration. surgical center is rarely advisable or indicated. All Here there is actual destruction of cerebral tissues. general surgeons should be familar with the technique It is commonly associated with depressed skull frac- of emergency temporal trephination (always bilater- ally), evacuation of the hematoma, and control of hemorrhage either by ligature, coagulation, application Presented at the 1964 USAREUR Medical-Surgical Training of silver clips or plugging of the foramen spinosum cwith hd bone wax, cotton, muscle or a wood applicator **Chief, Neurosurgical Service, U.S. Army General Hospital, ic n a on of Frankfurt, APO U.S. Forces 09757. stick inserted and broken off.

(M. Bull. U. S. Army, Europe U. S. ARMY, EUROPE 291

The intra-cranial epidural hematoma is one of the clinically by rhinorrhea (the exit of spinal fluid through few true neurosurgical emergencies. This hematoma the nasal or posterior nasal-pharyngeal passages), is commonly but not always associated with a fracture otorrhea (presence of spinal fluid in the middle ear of the temporal bone. with or without a perforation of the tympanic mem- b. . brane) or hematotympanum. This blood clot is located between the dura mater Basal skull fractures are frequently not visualized and the arachnoid covering the brain. When of suf- on routine x-ray views. X-ray confirmation is not ficient size it can cause cerebral compression. A sub- mandatory as it is the clinical condition which is dural hematoma is usually associated with other intra- treated. cranial injuries such as cerebral lacerations, diffuse cerebral edema and brain stem hemorrhages. The 1. Scalp lacerations. main therapy in a suspected case of subdural hema- Scalp lacerations with or without underlying frac- toma is not necessarily that of immediate surgical tures (diagnosed by gloved finger palpation and con- evacuation of the clot, but of general patient support firmed by x-ray since a lacerated galea frequently and the correction of respiratory obstruction and is confused with a linear fracture) should all be hyperthermia and then evacuation to a neurosurgical cleansed, debrided and closed primarily. This applies center for consideration of carotid angiography con- even when a known depressed fracture is present and trast studies and possible surgery. a craniectomy may be necessary. Early closure mark- It has been said that 900/o of patients with signifi- edly decreases the incidence of osteomyelitis, mening- cant-sized, acute subdural hematoma die with or with- itis and brain abscess. As a patient leaves the referring out surgery, due not primarily to the associated acute physician's hands, several hours have usually already intracerebral lesions. I do not feel that this high a elapsed and one cannot be certain when the patient statistic is necessarily true, but a high mortality rate will arrive at the neurosurgical center for intracranial is associated with this manifestation of head injury. debridement. The only exception to this policy of early closure after local debridement might be when c. Intracerebral hematomas. brain and blood clots are being extruded under pres- These lesions are associated with severe head trauma, sure and the overlying skin defect is being utilized are usually adequately localized by angiography and as an escape valve. External cleansing (do not wash then specifically neurosurgically operated upon. the brain proper with soaps, disinfectants, etc.) and ~3.~ Simple Fractures,. covering with a large loose sterile dressing is the , ,.mple ~only,Fractu. local care necessary. a. Linear non-depressed, simple skull fractures. These fractures mean nothing therapeutically ex- In the absence of a period of unconsciousness, a cept to alert the physician to the fact that consider- palpable fracture, alcoholism or anxious worried par- able trauma was sustained by that general area of ents, routine admission need not be performed for a the skull so that he will be alert for possible addi- scalp laceration. When any doubt is present in the tional intra-cranial damage. All patients with a diag- physician's mind, either referring or receiving, or nosed should be admitted for a minimum when doubt is expressed by an anxious parent, admis- of 48 hours of observation. sion is medically and legally advisable at the local hospital. b. Linear depressed, simple skull fractures. Any skull fracture whose inner table is depressed 2. Compound, non-depressed, linear convexity skull more than 1 cm. should be neurosurgically evaluated fractures, those overlying an air-sinus; or those basilar for possible bone elevation. Any skull fracture whose in type. inner table is depressed 5 mm. or more and is lying over a speech area or the motor cortex should be As with any skull fracture these patients are to be elevated. It is safe to say that when a depressed admitted. The convexity non-depressed fracture need fracture can be seen on an x-ray the damage is usu- nly have scal debridement, wound irrigation and ally greater than that surmised. Dural lacerations, local primary closure. The sinus fracture should be started cortical hemorrhage and resultant scarring are signi- o appropriate antibiotics, have overlying wound ficant associated defects. This type of patient need closure and referred to a neurosurgical center for not be evacuated as a dire emergency unless again further early care. there are focal signs attributable to the depressed Basal skull fractures should be started on antibi- fractures, or a suspected hematoma. otics and not necessarily have emergency evacuation c. Stellate fracture, simple. to a neurosurgeon. He too will only wait for the sub- sidence of the rhinorrhea, or otorrhea over a This is just a larger linear fracture and is evaluated idee o or otora era many-ay and handled as above. day period before instituting surgical and Handled as ab . repair a persistent fistula. therapy to d. Comminuted fractures, simple. If depressed elevation of the fracture will probably 3. Compound, depressed, convexity or inner table be necessary at an appropriate time during the pa- sinus fractures. tient'g period of treatment. The overlying wound should be cleansed, debrided and closed. The patient should then be placed on an- B. Compound Injuries. tibiotics and be expeditiously evacuated to a neuro- With rare exception (i.e., absence of bone, congeni- surgical center. This patient will then have a thorough tal or acquired), this type of injury is associated with craniectomy debridement of injured cerebral tissues. a skull fracture. This means a break in the skin over- Early thorough care of this type of injury markedly lying the site of a fracture, a fracture through an reduces the incidence of traumatic cerebral abscesses air-sinus area or a basal skull fracture manifested and meningitis.

Vol. 22, No. 8, August 1965) 292 MEDICAL BULLETIN

II. INDIRECT INJURIES TO THE CRANIUM AND involvement should be admitted for observation. INTRACRANIIAL CONTENTS. Clinically suspected epidural hematomas are best These are injuries which do not show external treated at the nearest surgically capable hospital. evidence of trauma but which can cause cerebral concussion, contusion, subdural hematoma (supra and All scalp lacerations should be cleansed and closed infratentorially), and death due to brain stem lesions. early except for those acting as escape valves for extruding intra-cranial contents. Cervical whiplash, transmission up the spinal axis extruding intracranial contents. tocks with impact transmission up the spinal axis All compound depressed skull fractures should into the head are examples of indirect injuries which have a thorough layer by layer debridement, prefer- may be responsible for intracranial damage. ably at a neurosurgical center. One must also be aware of opened or closed an- In case of doubt as to the extent of head injury, terior and lateral neck injuries which may be asso- always admit the patient for overnight observation. ciated with carotid artery thrombosis and vertebral artery occlusions which are surgical emergencies and NOTE: need angiographic confirmation of site followed by Neurosurgical consultation is always available to obstructive relief. obstructive relief anyone throughout the European Theater, at any time, SUMMARY by phone to help in making emergency decisions and Any head-injured patient with loss of consciousness even to direct emergency operations as has been done or with skull fracture or with other signs of cerebral beneficially in the past.

DENTAL X-RAY FILM OF THE MONTH

History: A 24-year-old soldier was referred for diag- nosis and treatment of an enlargement of the mandi- ble. The condition was noted approximately one year earlier and the mass had gradually increased in size. There was no pain or discomfort associated with the lesion and the patient's only concern was the cos- metic defect produced by the enlargement..;.-- Examination: A marked enlargement of the left side of the face was evident. Intra oral examination re..-...... vealed the buccal vestibule had been obliterated by a firm, nontender mass extending from the cuspid to the third molar region. Expansion of the buccal cortex was evident and, on hard palpation, crepitation was noted. The color of the overlying mucosa was normal. Teeth in the involved area were vital and skeletal survey and blood chemistry studies revealed no ab- iiiiiiiiiiiii----_iii- normalities. ?i??? Roentgenographic Findings: Roentgenograms revealed multiple, circular osteolytic lesions involving the body of the left mandible. Distinct bony septae were evi- ...... dent separating the individual osteolytic lesions. The mandibular canal had been displaced inferiorly and the bony cortex appeared to be involved by the osteo--,,'-,,','sg_ lytic lesi oIn.:."-.I:'g, . :iiiii-ii::iiiiiiiiiii:ii::iiiiii:?...... _ Differential Diagnosis: Differential diagnosis should include: Ameloblastoma, Ameloblastic fibroma, repara- tive giant cell granuloma, eosinophilic granuloma, and hyperparathyroidism. Diagnosis: See page 316.

(M. Bull. U. S. Army, Europe