‘Board’ out of my skull: penetrating skull fracture from a surfboard nose

摘要

A 45-year-old man attended our emergency department with a suspected scalp laceration sustained while surfing at a local break. He was an experienced surfer and described attempting to dive under an oncoming wave that contained a stray surfboard; this caught him on the head and broke in the process. He swam to shore and was transferred to hospital, via ambulance, where he was triaged as a non-urgent case. On examination, fibreglass debris was seen protruding from the wound that appeared to be deep to bone. He was subsequently transferred to resus and underwent a CT brain, demonstrating a penetrating skull fracture with a 30×10×10 mm foreign body in situ (figure 1). The images also demonstrated a small associated subdural haematoma, significant air in the subdural space and some minor midline shift (figure 2). The patient had no neurological features on history or examination. In discussion with the local neurosurgical team he was loaded on levetiracetam (Keppra), given intravenous antibiotic cover and transferred for surgical intervention. He underwent an emergency craniotomy and titanium cranioplasty to remove the segment of surfboard and a 30×30 mm section of contaminated, comminuted fractured skull to minimise the risk of osteomyelitis (figure 3). His postoperative course was uncomplicated although the infectious disease team were involved extensively due to the high risk of osteomyelitis. The patient initially had intravenous ciprofloxacin and clindamycin due to the saltwater exposure. Intraoperative cultures grew Propionibacterium acnes, commonly found in sebaceous follicules of healthy adults, and he was switched to oral amoxicillin and moxifloxacin.1