Agrawal, Amit

Kumar, Anand

Pratap, Akshay

Sinha, Abhishek

Thapa, Amit

English

eCommons@AKU

Pakistan Journal ofNeurological Sciences (PJNS)Volume 2 | Issue 1 Article 44-2007Multiple Fractures Upper Body Fracturesassociatedwith Extradural HematomasAmit AgrawalB.P. Koirala Institute of Health Sciences, Dharan, NepalAkshay PratapB.P. Koirala Institute of Health Sciences, Dharan, NepalAnand KumarB.P. Koirala Institute of Health Sciences, Dharan, NepalAmit ThapaB.P. Koirala Institute of Health Sciences, Dharan, NepalAbhishek SinhaB.P. Koirala Institute of Health Sciences, Dharan, NepalFollow this and additional works at: https://ecommons.aku.edu/pjnsPart of the Neurology CommonsRecommended CitationAgrawal, Amit; Pratap, Akshay; Kumar, Anand; Thapa, Amit; and Sinha, Abhishek (2007) "Multiple Fractures Upper BodyFracturesassociated with Extradural Hematomas," Pakistan Journal of Neurological Sciences (PJNS): Vol. 2 : Iss. 1 , Article 4.Available at: https://ecommons.aku.edu/pjns/vol2/iss1/4Multiple extradural hematomas,1 , 2 , 3 bilateral claviclef r a c t u r e ,4 first rib fracture,5 , 6 , 7 , 8 and second rib fracture,9either alone or in combination, are suggestive of significantand severe trauma. In the present case, the patientsustained multiple injuries due to multiple stones falling onhim. Patients with such findings need careful and detailede x a m i n a t i o n .CASE REPORTThis 47-year-old male presented when multiple stones fellon him while he was breaking stones in a quarry. Heexperienced transient loss of consciousness and chestpain. There was no history of vomiting, seizures, ear, nasalor oral bleed, or dyspnea. On examination, pulse rate was88 per minute, blood pressure was 120/84 mmHg andrespiratory rate was 24 per minute. His chest and cardiacexamination were normal, except for mild in-drawing of theintercostal muscles. There were no focal neurologicdefici ts. Local examinat ion showed crep itus andtenderness over both clavicles and tenderness over bothsides of the chest in the upper part. There was a laceratedwound (1 x 1 cm) over the right parietal region, withecchymosis of the right eye (Figure 1). There were multipleabrasions over the right clavicular region, as well as bothupper and the left lower limbs. Chest X-ray showed bilateralclavicle fractures, bilateral first rib fractures, and rightsecond rib fracture (Figures 2 and 3). Cervical and dorsalspine X-rays were normal. Brain CT scan showed rightbasal temporal and right fronto-parietal extraduralhaematomas with mass effect and midline shift (Figures 4and 5). The patient was treated successfully and did well.V O L .  2 ( 1 )   J A N  -  M A R  2 0 0 7P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  11C A S E  R E P O R TMULTIPLE FRACTURES UPPER BODY FRACTURESASSOCIATED WITH EXTRADURAL HEMATOMASAmit Agrawal, Akshay Pratap, Anand Kumar, Amit Thapa and Abhishek SinhaDepartment of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, NepalCorrespondence to: Dr. Agrawal, Assistant Professor of Neurosurgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.Telephone: 977-25-525555 ext 2047;Fax: 977-25-520251. Email: dramitagrawal@gmail.comABSTRACTAll patients with deceleration or crushing injuries involving clavicular and upper-rib fractures must be suspected of havingsignificant multiple organ system trauma, including intracranial trauma, and evaluated accordingly. This case illustrates theimportance of careful examination in an individual with a history of being hit by multiple objects, and thus having apossibility of multiple injuries.Figure 1: Photograph showing multipleabrasions on scalp and shoulder, andover the right clavicle.Figure 2: X-ray chest showing fractured right clavicle,and first and second rib (arrows).Pak J Neurol Sci 2007; 2(1):11-13D I S C U S S I O NFractures of the first rib are very rare and bilateralfractures are even less common. Traumatic fracturesusually involve not only the first rib but also the clavicleor scapula.5 , 1 0 First rib fractures are a harbinger of majortrauma as considerable force is required to fracture thefirst rib, which is protected very well by soft tissue as wellas the overlying clavicle and scapula.5 , 6 , 1 0 First r ibfractures may be isolated or occur in association withother rib fractures and are usually located in an area ofanatomical weakness (a shallow depression for thesub¬clavian artery).7 The mechanism of fracture iseither direct trauma to the shoulder (as in the presentcase) or a sudden violent contraction of juxtacostalmuscles. It may even be a chance finding, without anyhistory of trauma, and as such interpreted as a fatiguef r a c t u r e .8Fracture of the second rib is rare and only a few casereports are available.9 Bilaterally fractured claviclesusually result from direct trauma to both shoulders, as inthe present case. These fractures heal well with non-operative treatment.4The incidence of multiple extradural hematomas (EDH)has been reported in various studies ranging from 2-25%; these lesions are usually bilateral and presence atmore than two sites is extremely rare.1 , 3 It has beensuggested that the force of impact to the head canproduce bilateral hematomas, more predomi¬nant inthe antero-posterior direction than from the laterald i r e c t i o n .1 1 , 1 2 In this way, the dura can be detachedfrom two locations by a single directed force, andstripping of dura can occur at the site of impact by theskull bending inwards or outwards.1 1 This can be furtheraggravated by the negative intracranial pressure found atthe antipode of the compression force.1 3 These factorsprobably account for a higher frequency of EDH in thefrontal region.1 Indeed, the mechanism may be thesame as in coup and contre-coup injuries.1 4 In thepresent case the causes of ipsilateral double extraduralhematomas was multiple impacts due to falling stones (aconclusion supported by overlying skull fractures at bothsides). Patients with double EDH have a lucid intervalless frequently, have a lower Glasgow Coma Score,frequent ly lack la terali z ing find ings,  and tend todeteriorate more often than individuals with unilateralh e m a t o m a s .1 1 , 1 5All patients with deceleration or c rushing in juriesinvolving upper-rib fractures must be suspected of havingsignificant multiple organ system trauma and evaluateda c c o r d i n g l y .1 6 This case illustrates that in a personwhere there is a history of being hit by multiple objects,a possibility of multiple injuries must be considered.V O L .  2 ( 1 )   J A N  -  M A R  2 0 0 7P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  12Figure 3: CT scan showing right basal temporal extradural hematoma withoverlying fracture of squamous part of temporal bone (arrow).Figure 4: CT scan showing right fronto-parietal extradural haematoma withoverlying fracture of sphenoid bone (arrow).REFERENCES1. Huda MF, Mohanty S, Sharma V, et al. Double extradural haematoma: An analysis of 46 cases. Neurol India 2004; 52:450-452.2. Rivas JJ, Lobatto RD, Sarabia R, et al. Extradural haematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 1988; 23:44-51.3. Dharkar SR, Bhargava N. Bilateral epidural hematoma. Acta Neurochir 1991; 110:29-31.4. Sutherland AG, Knight DJ. Bilateral fractured clavicles--a pair of cases. Acta Orthop Belg 2000; 66:306-7. 5. Dwivedi S, Varma A. Bilateral fracture of the first ribs. J Trauma 1983; 538-9.6. Richardson JD, McElvein RB. First Rib Fracture: A Hallmark of Severe Trauma. Ann Surg 1975; 18:251-254.7. Albers JE, Rath RK, Glaser RS, et al. Severity of intrathoracic injuries associated with first rib fractures. Ann Thorac Surg 1982; 33:614-18. 8. Lorentzen JE, Movin M. Fracture of the first rib. Acta Orthop Scand. 1976; 47:632-4. 9. Jakubietz MG, Jakubietz RG, Gruenert JG, Langer M.Bilateral non-traumatic second rib fracture after bilateral first rib resection for TOS.  Thorax 2005; 60; 259-260. 10. Tsukada A, Uchiyama S, Toriumi H, et al. Nontraumatic bilateral first rib fractures. Acta OrthopBelg 1998; 64:406-8.11. Frank E, Berger TS, Tew JM Jr. Bilateral epidural hematomas. Surg Neurol 1982; 17:218- 22.12. Ramzan A, Wani A, Malik AH, Kirmani A, Wani MA. Acute Bilateral Extradural Hematomas. Neurol India2002; 50: 217-218.13. Gurdjian ES. Recent advances in the study of mechanism of impact of injury of the head. A summary. Clin Neurol 1972; 11:1-43. 14. Subrahmanian MV, Rajendra Prasad GB, Rao BD. Bilateral extradural hematoma. Br J Surg 1975; 62: 397-400. 15. Rasmussen GL, Holme S. Bilateral epidural hematomas. Ugeskr Laeger 1991; 154:203-4.16. Poole Jr. GV, Myers RT. Morbidity and Mortality Rates in Major Blunt Trauma to the Upper Chest. Ann Surg 1981; 193:70-75.V O L .  2 ( 1 )   J A N  -  M A R  2 0 0 7P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  13

Multiple Fractures Upper Body Fracturesassociated with Extradural Hematomas

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Multiple Fractures Upper Body Fracturesassociated with Extradural Hematomas

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