Skull fractures

Last reviewed: 7 Sep 2022
Last updated: 09 Apr 2021

Summary

Definition

History and exam

Key diagnostic factors

  • risk factors
  • open fracture
  • palpable discrepancy in bone contour
  • Battle's sign
  • periorbital ecchymosis
  • bloody otorrhoea
  • cerebrospinal fluid rhinorrhoea
  • facial paralysis, nystagmus, or paraesthesia
Full details

Other diagnostic factors

  • evidence of trauma
  • cranial pain or headache
  • nausea/vomiting
  • altered mental state/loss of consciousness
  • abnormal pupillary reflexes
  • hearing loss
Full details

Risk factors

  • fall from height
  • motor vehicle accident
  • assault resulting in head trauma
  • gunshots to the head
  • male sex
Full details

Diagnostic investigations

1st investigations to order

  • cranial CT
Full details

Investigations to consider

  • skeletal survey
  • MRI
  • MR angiography
  • beta-2 transferrin assay
  • plain skull x-ray
  • clotting screen
Full details

Treatment algorithm

INITIAL

suspected skull fracture (any type)

ACUTE

confirmed closed non-depressed fracture

confirmed closed depressed fracture

confirmed open fracture

ONGOING

persistent cranial nerve injury or CSF leakage

Contributors

Expert advisers

Demetrios Demetriades, MD, PhD, FACS

Professor of Surgery

Director

Division of Trauma and Surgical Intensive Care

LAC+USC Trauma Center

Keck School of Medicine at USC

University of Southern California

Los Angeles

CA

Disclosures

DD declares that he has no competing interests.

Leslie Kobayashi, MD, FACS

Associate Professor of Surgery

Division of Trauma, Surgical Critical Care and Burns

University of California San Diego

San Diego

CA

Disclosures

LK declares that she has no competing interests.

Peer reviewers

Kevin Tsang, MBBS, BSc (Hons), MRCS (Eng), FRCS (SN)

Consultant Neurosurgeon

Unit Training Lead and Clinical Teacher

Imperial College Healthcare NHS Trust

London

UK

Disclosures

KT declares that he has no competing interests.

Editors

Tannaz Aliabadi-Oglesby,

Lead Section Editor, BMJ Best Practice

Disclosures

TAO declares that she has no competing interests.

Jo Haynes,

Head of Editorial, BMJ Knowledge Centre

Disclosures

JH declares that she has no competing interests.

Annabel Sidwell,

Comorbidities Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

  • Skull fractures images
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  • Guidelines

    • Head injury: assessment and early management
    • Clinical practice guideline for paediatric head injury
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  • Calculators

    Glasgow Coma Scale

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