Most common causes include a fall, a 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.
CT, with thin axial cuts, remains the imaging modality of choice. With basilar skull fractures, 3D reconstructions are useful.
May be associated with other significant injuries, most importantly intracranial hemorrhage.
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 categorized according to the appearance, location, degree of depression, and if 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
- open fracture
- palpable discrepancy in bone contour
- Battle sign
- periorbital ecchymosis
- bloody otorrhea
- cerebrospinal fluid rhinorrhea
- facial paralysis, nystagmus, or paresthesia
Other diagnostic factors
- evidence of trauma
- cranial pain or headache
- altered mental state/loss of consciousness
- abnormal pupillary reflexes
- hearing loss
- male sex
- fall from height
- motor vehicle accident
- assault resulting in head trauma
- gunshots to the head
1st investigations to order
- cranial CT
Investigations to consider
- MRI angiography
- beta-2 transferrin assay
- cranial ultrasound
- plain skull x-ray
- skeletal survey
closed nondepressed fracture
closed depressed 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.
Tunji Lasoye, FRCS, FCEM, MA, Med Ed
Consultant and Honorary Senior Lecturer in Emergency Medicine
Director of Medical Education
King's College Hospital
TL declares that he has no competing interests.
Micelle J. Haydel, MD
LSU Emergency Medicine Residency
Louisiana State University
MJH declares that she has no competing interests.
Thomas Scalea, MD
Physician in Chief
R Adams Cowley Shock Trauma Center
Francis X. Kelly Professor of Trauma Surgery
University of Maryland School of Medicine
TS declares that he has no competing interests.
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