Skull fractures are most commonly caused by a fall, a road traffic accident, or an assault.
Skull fractures may be linear or comminuted with multiple fracture lines, may be located on the cranial vault or in the basilar skull, may have a varying degree of depression or elevation, and can be open or closed. Open fractures communicate with the skin through a wound, a sinus, the ear, or the oropharynx.
Computed tomography (CT), with thin axial cuts, remains the imaging modality of choice. With basilar skull fractures, three-dimensional reconstructions are useful.
May be associated with other significant injuries, most importantly intracranial haemorrhage.
For isolated skull fractures, treatment is primarily conservative.
Surgical intervention is determined not by the fracture per se but by extent of associated intracranial pathology, cranial nerve deficit, or cerebrospinal fluid leak.
Skull fracture refers to a fracture of one or more bones of the cranial vault or skull base. They are categorised according to the appearance, location, degree of depression, and according to whether they are open or closed. Open fractures communicate with the skin through a wound, a sinus, the ear, or the oropharynx. Skull fractures may be linear or comminuted; comminuted fractures are complex with multiple fracture lines.
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
Other diagnostic factors
- evidence of trauma
- cranial pain or headache
- altered mental state/loss of consciousness
- abnormal pupillary reflexes
- hearing loss
- fall from height
- motor vehicle accident
- assault resulting in head trauma
- gunshots to the head
- male sex
1st investigations to order
- cranial CT
Investigations to consider
- skeletal survey
- MR angiography
- beta-2 transferrin assay
- plain skull x-ray
- clotting screen
suspected skull fracture (any type)
confirmed closed non-depressed fracture
confirmed closed depressed fracture
confirmed open fracture
persistent cranial nerve injury or CSF leakage
Demetrios Demetriades, MD, PhD, FACS
Professor of Surgery
Division of Trauma and Surgical Intensive Care
LAC+USC Trauma Center
Keck School of Medicine at USC
University of Southern California
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
LK declares that she has no competing interests.
Kevin Tsang, MBBS, BSc (Hons), MRCS (Eng), FRCS (SN)
Unit Training Lead and Clinical Teacher
Imperial College Healthcare NHS Trust
KT declares that he has no competing interests.
Lead Section Editor, BMJ Best Practice
TAO declares that she has no competing interests.
Head of Editorial, BMJ Knowledge Centre
JH declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
AS declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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