As bad as it looked, the hit sustained last Friday by Montreal Canadiens prospect Blake Geoffrion – which resulted in a skull fracture, seizures, emergency surgery, and the placement of a metal plate in his head – could have been even worse. Geoffrion is now stable and on the mend after suffering a depressed skull fracture while playing for the American Hockey League’s Hamilton Bulldogs, an injury that easily could have taken his life.
The 24-year old prospect was racing with the puck down the left side of the rink when he took a hit from Syracuse Crunch defenseman Jean-Phillipe Cote that sent Geoffrion flying into the boards. When he crashed to the ice, the left side of Geoffrion’s head landed on Cote’s skate, fracturing his skull and resulting in a chain of events that led him to the operating room.
The impact of Geoffrion’s head hitting Cote’s skate at high velocity resulted in a type of injury known as a depressed skull fracture, which occurs when a piece of skull is pushed inward, somewhat like what occurs when a ping pong ball is pressed in. The sequence of events that often follows can be grave without immediate intervention, the reasons which have to do with the intricate anatomy of the skull and brain structures beneath it.
The skull is made up of many bones that form a protective covering for the brain. When a traumatic force is applied to these bones, their strength and alignment is usually sufficient to prevent significant damage to the brain itself. However, a significant enough force can cause a fracture, and when the integrity of the bone is compromised, the specific location of the fracture plays an important role in determining the severity of the injury.
Location is important because some skull bones are thinner and more fragile than others. Geoffrion’s fracture, for example, occurred to the temporal bone above the ear, which is relatively thin and can be more easily broken than others, such as occipital bone at the back of the skull. When a depressed fracture occurs, the structures underlying the bone – the brain itself, as well as nerves, blood vessels, and the dura mater holding cerebrospinal fluid – can be damaged by the broken bone, and in the most severe cases patients may experience loss of consciousness, increased pressure inside the skull due to build up of fluids such as blood, and swelling of the brain.
If patients do not experience any neurological changes suggestive of increased pressure inside of the skull (e.g., severe headache, sudden loss of consciousness, or seizures), they may be treated conservatively with observation alone. These fractures heal well with time, with little or no residual effects. However, in more severe cases such as Geoffrion’s – who not only had an opening in his scalp due to hitting the skate but also began to show signs of mental status changes shortly after arriving at the hospital, including seizure – surgery is usually required.
The specific criteria for surgical repair of a depressed skull fracture include:
* A depression greater than 8-10mm
* Brain function difficulties related to pressure or injury of the underlying brain
* Leakage of cerebrospinal fluid
*A fracture associated with a cut in the scalp
Surgical repair involves a number of steps, the primary of which is to elevate the depressed fragment and inspect the underlying structures for any damage. If there is leakage of blood or cerebrospinal fluid due to damage to vessels of the dura mater, these fluids need to be removed and the damaged structures must be repaired.If there are signs of increased pressure within the skull or swelling of the brain, often times the depressed fragment will be removed until the pressure has subsided.
And in cases where the fragmenting has been complex or replacing the depressed piece would be difficult, the area is patched with a metal plate-like structure often made of titanium and mesh. If surgery is performed quickly, as was the case for Geoffrion, the prognosis for a full recovery is excellent. Patients usually require antibiotics and anticonvulsant medications for a period of time following surgery, and treatment with the latter can often be prolonged due to an increased risk of seizures following this type of injury.
Geoffrion, who left the intensive care unit less than 48 hours after surgery and by all accounts has been doing very well since, is expected to miss a significant amount of time as he recovers from one of the most frightening injuries we’re likely to see this year. But thanks to early recognition and action on the part of his medical team, his pro hockey career may not be done just yet.