The importance of a head injury is not whether the patient has been knocked out, nor even whether the skull has been fractured in the process, but whether or not the injury has caused damage to, or pressure on the brain. This pressure can come from a number of sources, such as bleeding – either into the brain or underneath the skull – which presses on the brain, or else from a depressed fracture where the bones themselves are pressing directly on the brain.
All other considerations are secondary. To be honest, after a head injury, it really doesn’t matter if the patient has sustained a fractured skull – the bones of the skull are just like other bones of the body, and will heal. A hairline crack or fracture is really of little importance (other than that it causes pain), as long as there is no bleeding underneath, or swelling of the brain substance.
This can’t be emphasised enough. All too often, people imagine that it’s the concussion that we should look out for, or the fractured skull that is so important. That isn’t the case. The only reason for admitting a patient to hospital after concussion or a fractured skull is that a blow big enough to cause concussion is hard enough to rip nerves and blood vessels within the brain or cause swelling of the brain itself; and where there is a fractured skull there may also be treacherous and unseen underlying bleeding. So the patient” is admitted, and observed carefully for the next twenty-four hours, to spot any signs of progressive internal injury.
Most head injuries result in simple superficial bruising; a small proportion concuss the patient. Harder blows may cause a skull fracture, though the position and angle of the blow often determines whether or not the skull will fracture. One part of the head is particularly prone to direct fracture – the temple (at the side of the head, between the eye and ear) is the most vulnerable area for fractures that are the result of a direct blow from a small object, such as a golf ball.
A simple undisplaced fracture of the skull (where the bones haven’t moved) is usually relatively unimportant. Provided there is little bleeding from the broken edges of the bone, then a crack in the skull bones can be treated much like a crack in any other bone, such as at the wrist. In fact, because the skull is such a solid, well-constructed egg shape, even if there is a crack, the edges of the bone are usually held closely together and will soon heal without needing bandaging or plaster to hold the ends of the broken bones opposite one another.
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