Role of preoperative 3-dimensional computed tomography reconstruction in depressed skull fractures treated with craniectomy: a case report of forensic interest

Depressed fractures of the skull due to direct kick and the contribution of 3D CT reconstruction

Depressed skull fractures occur when broken bones displace inward, meaning that a portion of the outer table of the fracture line lies below the normal anatomical position of the inner table. They typically result from force trauma, when the skull is struck by an object with a moderately large amount of kinetic energy but a small surface area, or when an object with a large amount of kinetic energy impacts only a small area of the skull. In the present case, a depressed fracture of the frontal bone was detected at the autopsy of a 52-year-old man who, according to the belated confession of the assailant, was kicked in the head. The assailant was wearing sneakers. Could such a fracture be caused "just" by a kick? In this case it was possible due to an extraordinarily thin cranial vault (0.2 cm frontal, 0.3 cm occipital), which allowed the fractures to occur from a kinetic force that might not have been sufficient with a normal cranial vault thickness. An important role in the forensic analysis of the case was played by the 3D CT reconstruction.

Skull fractures in pediatric patients on computerized tomogram: comparison between routing bone window images and 3D volume-rendered images

Skull fracture is a common finding following head trauma. It has a prognostic significance and its presence points to severe trauma. Additionally, there is a greater possibility of detecting associated small underlying extra-axial hematomas and subtle injuries to the brain parenchyma. In pediatric patients, the presence of multiple open sutures often makes fracture evaluation challenging. In our experience, 3D volume (3DV)-rendered CT images complement routine axial bone window (RBW) images in detection and characterization of fractures. This is a multi-reader, multi-case, paired retrospective study to compare the sensitivity and specificity of RBW and 3DV images in detection of calvarial fractures in pediatric patients. A total of 60 cases (22 with fractures and 38 without) were analyzed. Two experienced neuroradiologists and a radiology trainee were the readers of the study. For all readers, the sensitivity was not statistically different between the RBW and the 3DV interpretations. For each reader, there was a statistically significant difference in the interpretation times between the RBW and the 3DV viewing formats. A greater number of sutural diastasis was identified on 3DV. We propose that 3DV images should be part of routine head trauma imaging, especially in the pediatric age group. It requires minimal post-processing time and no additional radiation. Furthermore, 3DV images help in reducing the interpretation time and also enhance the ability of the radiologist to characterize the calvarial fractures.

A simple depressed skull fracture in an old man with Paget disease: forensic implications in a rare case

Skull fractures occur when forces striking the head exceed the mechanical integrity of the calvarium. A depressed skull fracture is a break in a cranial bone with depression of the bone into the brain. A depressed fracture may be open (compound), with a skin laceration over the fracture, or closed (simple), when the overlying tissue is not disrupted. The association between simple depressed fracture of the skull and elderly is rare. Paget disease of the bone is a chronic disease characterized by the deposition of abnormal bone tissue, more fragile than normal bone. We report a case of a 92-year-old man who was found supine on the floor in his residence, showing multiple signs of trauma. X-rays and computed tomography scans were performed, showing a simple depressed skull fracture on the right occipital-temporal area and even the characteristics of Paget disease of the skull. The first hypothesis was death due to voluntary homicide. A detailed study of clinical reports, laboratory tests, radiograph scans, and post mortem examination data allowed us to reconstruct the event. Death was finally ruled due to a mild passive trauma, suggesting the unlawful killing of a human without criminal intent, meaning involuntary manslaughter.