Skull fracture

This page is for adult patients. For pediatric patients, see: skull fracture (peds).

Background

Bones of the cranium.

• Presence of skull fracture significantly increases risk of underlying intracranial injury

Clinical Features

Linear Skull Fracture

• Often have scalp hematoma or tenderness to palpation

Depressed Skull Fracture

• Depression or crepitus may be palpable on physical exam

Basilar Skull Fracture

• Raccoon eyes
• Battle sign
• Hemotympanum
• Clear rhinorrhea or otorrhea may indicate CSF leak from dural tear associated with fracture

Differential Diagnosis

Head trauma

• Traumatic brain injury
  • Intracranial hemorrhage
  • Moderate-to-severe traumatic brain injury
    • Elevated intracranial pressure
  • Mild traumatic brain injury
    • Clinical decision rules for head CT in trauma
    • Post-concussive syndrome
• Orbital trauma
• Maxillofacial trauma
• Skull fracture
  • Basilar skull fracture
  • Skull fracture (peds)
• Pediatric head trauma
  • PECARN head trauma rule

Maxillofacial Trauma

• Auricular hematoma
• Dental trauma
• Head trauma (main)
• Le Fort fractures
• Mandible fracture
• Nasal fracture
• Nasal septal hematoma
• Orbital trauma
  • Globe rupture
• Skull fracture
  • Basilar skull fracture
  • Skull fracture (peds)
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture

Evaluation

• CT head
• CBC
• Coags
• Evaluate for additional injuries

Management

Linear Skull Fracture

• If no intracranial bleed or other injuries, observe for 4-6 hrs and discharge
  • Patients with advanced age, coagulopathy, or other co-morbidities may benefit from admission

Depressed Skull Fracture

• Neurosurgery consult
• Antibiotics, seizure prophylaxis (e.g. Keppra), surgery/wound debridement may be indicated in discussion with a neurosurgeon

Basilar Skull Fracture

• Neurosurgery consult
• Antibiotic prophylaxis is often started in setting of CSF leak but should be discussed with a neurosurgeon

Disposition

• Admit - except for simple linear skull fracture with no other injuries

See Also

• Skull fracture (peds)