Skull fractures

Last reviewed: 7 Jan 2023
Last updated: 16 Aug 2022



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
  • MRI angiography
  • beta-2 transferrin assay
  • audiogram
  • 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

Associate 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

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.

Micelle J. Haydel, MD

Program Director

LSU Emergency Medicine Residency

Louisiana State University

New Orleans



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.

  • Skull fractures images
  • Differentials

    • Intracranial hemorrhage
    • Suture lines in children
    • Cephalhematoma
    More Differentials
  • Guidelines

    • Head injury: assessment and early management
    • Guideline on the diagnosis and management of mild traumatic brain injury among children
    More Guidelines
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer