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Skull fractures

Last reviewed: 28 Oct 2023
Last updated: 20 Sep 2023



History and exam

Key diagnostic factors

  • open fracture
  • palpable discrepancy in bone contour
  • Battle sign
  • periorbital ecchymosis
  • bloody otorrhea
  • cerebrospinal fluid rhinorrhea
  • facial paralysis, nystagmus, or paresthesia
More key diagnostic factors

Other diagnostic factors

  • evidence of trauma
  • cranial pain or headache
  • nausea
  • altered mental state/loss of consciousness
  • abnormal pupillary reflexes
  • hearing loss
Other diagnostic factors

Risk factors

  • fall from height
  • motor vehicle accident
  • assault resulting in head trauma
  • gunshots to the head
  • male sex
More risk factors

Diagnostic investigations

1st investigations to order

  • cranial CT
More 1st investigations to order

Investigations to consider

  • MRI
  • MR angiography
  • beta-2 transferrin assay
  • cranial ultrasound
  • plain skull x-ray
  • skeletal survey
  • CT angiogram
  • CT venogram
More investigations to consider

Treatment algorithm


closed nondepressed fracture

closed depressed fracture

open fracture


persistent cranial nerve injury or CSF leakage



Demetrios Demetriades, MD, PhD, FACS
Demetrios Demetriades

Professor of Surgery


Division of Trauma and Surgical Intensive Care

LAC+USC Trauma Center

Keck School of Medicine at USC

University of Southern California

Los Angeles



DD declares that he has no competing interests.

Leslie Kobayashi, MD, FACS
Leslie Kobayashi

Professor of Surgery

Division of Trauma, Surgical Critical Care and Burns

University of California San Diego

San Diego



LK declares that she has no competing interests.

Peer reviewers

Prof Sherard Austin Tatum, MD

Professor Otolaryngology and Pediatrics

SUNY Upstate Medical University


New York


SAT declares that he has no competing interests.

Tunji Lasoye, FRCS, FCEM, MA, Med Ed

Consultant and Honorary Senior Lecturer in Emergency Medicine

Clinical Lead

Emergency Department

Director of Medical Education

King's College Hospital




TL declares that he has no competing interests.

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