Penetrating Skull Fracture

hauntedwriter said:

In my story, my main character in a basement. It's a low ceiling, almost crawl space, cramped basement. When he looks up, he sees the beams of the ceiling along with nails protruding out. At the end of the story, he's in the basement, something happens and he turns around. But in doing so, he inadvertently stands. When he stands, he stands up into on the nails. I have him dropping straight down. He starts to feel the blood trickle down and he blacks out.

My question is: what happens next? I've looked online but can't find what would happen. He wakes up in the hospital. I have that. But what types of testing would be done with that type of penetrating injury? Tetanus shot? Just x-rays?

The character doesn't die from this wound but I just would like to know what would be said to him once he wakes up and is fully conscience of where he is and what had happened. What would the doctor say to him, or his wife, about what they (the hospital) did to him?

Thank you for your time!

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I'm an ICU doc and head injuries are part of my usual gig. I have a couple of thoughts to answer your questions.

1. I disagree with other folks that such a mechanism of injury can't penetrate the skull. It could, especially if the nail hit the head at right angles. Your scenario has to involve sufficient force to cause a severe concussion because you want loss of consciousness. That much force could drive the nail entirely through the skull. I've actually seen injuries like that.

2. Bleeding from the scalp would be there, but since it would be a puncture and not a gash the bleeding would probably be modest unless he hit a blood vessel. But there certainly could be enough for your scenario. As CWatts points out, the scalp is notorious for bleeding a lot from a laceration.

3. The x-ray study that would be done would be a head CT without IV contrast. What they would do next would depend upon what they found. If there was ongoing bleeding in the brain he would go right to the operating room. Even if there was no active bleeding or large clot he probably would still have his brain explored to irrigate the wound area and remove any debris (bits of hair, bits of nonviable brain, bone fragments, anything else that got in). He would get a tetanus shot if it's been longer than 5 years since his last one as well as IV antibiotics. If he were my patient I'd keep him on IV antibiotics for 7-10 days.

4. You also should think about the location of the puncture. An injury like that to the frontal lobe could easily cause no neurological defect at all. So if you want that outcome hit the frontal lobe nearer to the forehead. An injury to the back of the frontal lobe or the front part of the parietal lobe would probably (but not necessarily) cause some damage to motor or sensory function. The defect would be on the side of the body opposite to the injury, since the nerve fibers cross on their way down. If you want that kind of injury have it on the side of the head above the ear. Any neurological defect would be apparent when he wakes up and would not develop later. If you want an injury that he's likely to recover from completely, drive the nail in maybe 1 cm into the frontal lobe (don't forget to allow for the thickness of the skull). If you want an injury that gives a neurological defect that he later recovers from you could have a scenario in which there is some brain swelling around the area of injury that resolves over the next couple of days.

5. If he wakes up from surgery without a neurological deficit the doctors would say he should be OK ultimately. If he has a deficit the doctors would be more guarded, probably saying "we'll wait and see -- no predictions." If you want some complications in a few days, infection, such as an abscess, would be very plausible.

Hope this helps