Infected open depressed skull fracture complicated with tetanus grade I in an unimmunized child: a rare case report with literature review

Background Tetanus is a rare disease caused by Clostridium tetani, which produces tetanolysin and tetanospasmin. In 2018, there were only approximately ten tetanus cases reported in Indonesia. Despite widespread vaccination, especially in low–middle-income countries, tetanus still occurs (mostly in adults) due to the lack of immunization related to religious tenets, cultural belief, or inaccessibility to medical care. In addition, tetanus in the pediatric population shows features which are quite distinct from the adult group. Case presentation We report a case of a 7-year-old girl presented to our institution with a history of falling 10 days prior to admission, with only skin laceration on her forehead. For 1 day prior to admission, the patient looked drowsy and difficult to be awakened, accompanied with stiffness of her jaw; we diagnosed her as an unimmunized child with an open depressed skull fracture of her frontal bone and wound infection complicated with “lockjaw.” Perioperative management of this rare case is reported and discussed. Conclusion The pediatric intensive care of such patients requires halting further toxin production, neutralization of circulating toxin, and control of the clinical manifestation induced by the toxin that has already gained access to the central nervous system. The basic tenets of anesthetic care in such case must be well-managed and planned prior to surgery.

Management Of Depressed Skull Fracture

Background: Head injury is the most serious problem all around the world. Over the last 200 years both surgical and conservativemanagement have been evolved. Chronological surgical management yields better outcome by decreasing mortality andmorbidity. Wound debridement, repair of dural defect and closure of wound are standard principles in management.Objective: To study the outcomes of surgical management of depressed skull fracture.Material and methods: This study was conducted in Shifa Medical center from 1st June 2016 to 30thJune 2019. Clinical featurescause, and computerized tomography (CT) pictures were compiled in proforma. Whenever depressed fracture size exceeded than5mm, cosmetically disfiguring and fracture over the sinus were operated. All the patients were followed for six months.Results: Total of 60 patients were included 42 patients (70%) were male and 18(30%) were female. Pediatric population was majorcontributor 36 out of 60 patients (ratio60%). 56 patients (93.33%)operated, 4 patients (6.67%) were treated conservatively. These 4patients(6.67%) had severe head injury and were put on ventilator 32 patients (53.3%)fully recovered, 12 patients (20%) hadmoderate disability, 8 patients (13%) had severe disability and 3 patients(4.8%)pass away in this study.Conclusion: It was found that, depressed skull fracture was mostly common in children. Usage of antibiotic and anticonvulsantshad effective results in term of preventing infection and epilepsy during perioperative period. Initial stage surgical treatment isexceptionally required where size of fracture exceed 5mm. Outcome depended upon the sternness of injury and existence ofassociated intra cerebral lesion.Key words: surgical management, depressed skull fracture (DSF) and CSF leakage.