Skull fractures (summary)

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  This is a basic article for medical students and non-radiologists

Skull fractures usually occur following significant head injury and may herald underlying neurological pathology.

Epidemiology

Accurate incidence and prevalence are unknown, but there are 1.3 million traumatic brain injuries in the US per year ¹ and it is expected that a third of these will have an underlying skull fracture.

Clinical presentation

Skull fractures occur in high energy trauma: in children and elderly, falling is the main mechanism of injury, while in adults motor vehicle collisions are the most frequent cause ¹.

Patients will usually display neurological signs associated with other sustained injuries, e.g. EDH, SDH, SAH, contusions.

In basal skull injuries, there may be complaints of CSF rhinorrhoea or otorrhoea. In these cases and with open/depressed fractures, there is a high risk of CNS infection/meningitis as the dura will have also been breached. Other signs consistent with basal skull fracture include Battle's sign (bruising over the mastoid process) or "raccoon eyes" (black eyes).

Pathology

There are different types of skull fracture to consider:

• linear
• depressed (open fractures)
• diastatic (widening suture lines in childhood)
• basilar

There may also be bone fragments under the fractures and other penetrating injuries.

Radiographic findings

CT

This is the best method for looking for bony injury and any underlying extra-axial haemorrhage or parenchymal insult.

Examining with the bone and soft tissue windows is important, with other signs including pneumocephalus or bleeding into paranasal sinuses.

3D reconstruction is also possible with CT imaging.

Treatment and prognosis

All patients in suspected head injury should be appropriately managed and worked up following ATLS principles (C-spine control and ABCDE) and assessment of Glasgow Coma Score.

Linear fractures do not usually require any specific treatment.

Depressed fractures will often need neurosurgical intervention to prevent further brain insult and reduce infection risk.

Basal fractures are often unstable and carry high risks of morbidity and require expert care ².