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Skull fracture vs. accessory sutures: how can we tell the difference?

Sanchez T, Stewart D, Walvick M, Swischuk L - Emerg Radiol (2010)

View Article: PubMed Central - PubMed

Affiliation: University of California Davis, Sacramento, CA, USA. thomas.sanchez@ucdmc.ucdavis.edu

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Plain film radiography remains the most cost effective method in evaluating skull fractures and can easily differentiate major sutures and common vascular grooves from fractures... Therefore if cranial CT is deemed clinically necessary in trauma patients, questionable fractures can be confidently differentiated from unusual accessory sutures using these additional workstation capabilities... One study has shown that at least 4 mm of soft tissue swelling was present on the cranial CT scan in all cases of acute skull fractures that they reviewed... However, absence of subgaleal hematoma or swelling does not entirely rule out a fracture especially if the injury is remote or imaging was performed several days after the trauma... CT scan with 3D reconstruction was performed and showed a well-defined lucency extending into the lambdoid suture... There is no associated diastasis or widening and it does not extend into the foramen magnum posteriorly... A fracture usually will show evidence of healing or sclerosis in two or three months... In summary, fractures and accessory sutures can be differentiated in most cases by observing its characteristics such as bilaterality, symmetry, associated diastasis, and presence of soft tissue swelling (Table 1)... Knowledge of the normal anatomy, development, and timing of sutural closure are also necessary to decipher the varied and sometimes complex nature of these accessory sutures especially in the occipital region... However, in difficult cases, it is prudent to request for a follow-up study to look for signs of healing.

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a Notice how the fracture line is narrow proximally but progressively widens as it extends into the sagittal suture. b In a different patient, the left occipital bone fracture (arrow) extends into and slightly widens the posterior intraoccipital synchondrosis (small arrow)
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Fig4: a Notice how the fracture line is narrow proximally but progressively widens as it extends into the sagittal suture. b In a different patient, the left occipital bone fracture (arrow) extends into and slightly widens the posterior intraoccipital synchondrosis (small arrow)

Mentions: Simple non-depressed skull fractures are sharp lucencies with non-sclerotic edges. In contrast, accessory sutures usually will show a zigzag pattern with interdigitations and sclerotic borders similar to major calvarial sutures (Fig. 3). When fractures extend into a major suture, there could be widening of the fracture line as it approaches the suture or there is associated diastasis of the adjacent synchodrosis or suture. (Fig. 4). An accessory suture will usually not produce this appearance. High impact fractures can cross suture lines or extend from one major suture to another, whereas accessory sutures join and merge with the major suture (Fig. 5). In terms of bilaterality, accessory sutures are often present on both sides and are fairly symmetric especially in the parietal bones [2]. Occipital accessory sutures can be complex and multiple but are also frequently bilateral [5]. However, skull fractures can be also bilateral. When they are, these fractures are almost always associated with high impact injuries and thus will often show comminution, depression, and marked asymmetry. Hence, these complex and high impact fractures are almost never confused with developmental variants [6, 7]. Finally, soft tissue swelling or hematoma is frequently associated with acute skull fractures. One study has shown that at least 4 mm of soft tissue swelling was present on the cranial CT scan in all cases of acute skull fractures that they reviewed [8]. However, absence of subgaleal hematoma or swelling does not entirely rule out a fracture especially if the injury is remote or imaging was performed several days after the trauma [9]. Its presence though is highly suggestive of an acute traumatic event. (Fig. 6).Fig. 3


Skull fracture vs. accessory sutures: how can we tell the difference?

Sanchez T, Stewart D, Walvick M, Swischuk L - Emerg Radiol (2010)

a Notice how the fracture line is narrow proximally but progressively widens as it extends into the sagittal suture. b In a different patient, the left occipital bone fracture (arrow) extends into and slightly widens the posterior intraoccipital synchondrosis (small arrow)
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC2914264&req=5

Fig4: a Notice how the fracture line is narrow proximally but progressively widens as it extends into the sagittal suture. b In a different patient, the left occipital bone fracture (arrow) extends into and slightly widens the posterior intraoccipital synchondrosis (small arrow)
Mentions: Simple non-depressed skull fractures are sharp lucencies with non-sclerotic edges. In contrast, accessory sutures usually will show a zigzag pattern with interdigitations and sclerotic borders similar to major calvarial sutures (Fig. 3). When fractures extend into a major suture, there could be widening of the fracture line as it approaches the suture or there is associated diastasis of the adjacent synchodrosis or suture. (Fig. 4). An accessory suture will usually not produce this appearance. High impact fractures can cross suture lines or extend from one major suture to another, whereas accessory sutures join and merge with the major suture (Fig. 5). In terms of bilaterality, accessory sutures are often present on both sides and are fairly symmetric especially in the parietal bones [2]. Occipital accessory sutures can be complex and multiple but are also frequently bilateral [5]. However, skull fractures can be also bilateral. When they are, these fractures are almost always associated with high impact injuries and thus will often show comminution, depression, and marked asymmetry. Hence, these complex and high impact fractures are almost never confused with developmental variants [6, 7]. Finally, soft tissue swelling or hematoma is frequently associated with acute skull fractures. One study has shown that at least 4 mm of soft tissue swelling was present on the cranial CT scan in all cases of acute skull fractures that they reviewed [8]. However, absence of subgaleal hematoma or swelling does not entirely rule out a fracture especially if the injury is remote or imaging was performed several days after the trauma [9]. Its presence though is highly suggestive of an acute traumatic event. (Fig. 6).Fig. 3

View Article: PubMed Central - PubMed

Affiliation: University of California Davis, Sacramento, CA, USA. thomas.sanchez@ucdmc.ucdavis.edu

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Plain film radiography remains the most cost effective method in evaluating skull fractures and can easily differentiate major sutures and common vascular grooves from fractures... Therefore if cranial CT is deemed clinically necessary in trauma patients, questionable fractures can be confidently differentiated from unusual accessory sutures using these additional workstation capabilities... One study has shown that at least 4 mm of soft tissue swelling was present on the cranial CT scan in all cases of acute skull fractures that they reviewed... However, absence of subgaleal hematoma or swelling does not entirely rule out a fracture especially if the injury is remote or imaging was performed several days after the trauma... CT scan with 3D reconstruction was performed and showed a well-defined lucency extending into the lambdoid suture... There is no associated diastasis or widening and it does not extend into the foramen magnum posteriorly... A fracture usually will show evidence of healing or sclerosis in two or three months... In summary, fractures and accessory sutures can be differentiated in most cases by observing its characteristics such as bilaterality, symmetry, associated diastasis, and presence of soft tissue swelling (Table 1)... Knowledge of the normal anatomy, development, and timing of sutural closure are also necessary to decipher the varied and sometimes complex nature of these accessory sutures especially in the occipital region... However, in difficult cases, it is prudent to request for a follow-up study to look for signs of healing.

Show MeSH
Related in: MedlinePlus