Skull fractures (summary)

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

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

Reference article

This is a summary article; read more in our article on skull fractures.

Summary

• anatomy
  • cranial vault
  • base of the skull
• epidemiology
  • accurate incidence and prevalence unknown
  • 1.3 million traumatic brain injuries per year in the USA
    • estimated that 1/3 will have a skull fracture
• presentation
  • head injury following impact trauma, e.g. fall, RTC
  • symptoms associated with underlying injury
    • extradural hemorrhage
    • subdural hemorrhage
    • subarachnoid hemorrhage
  • there may be an associated base of skull injury
    • CSF rhinorrhea
    • Battle sign (bruising over mastoid process)
    • raccoon eyes
• pathophysiology
  • mechanism
    • children and elderly: simple fall
    • adults: usually high-energy impact trauma, e.g. RTC
  • different types of fractures
    • linear
    • depressed skull fracture
    • diastatic (widening suture lines in childhood)
    • base of skull fracture
    • growing skull fracture
    • ping pong fracture
  • associations
    • bone fragments under the fracture
    • other penetrating injuries
    • intracranial hemorrhage
• treatment
  • head injury patients should be treated following ATLS (or similar)
    • C-spine control and ABCDE
    • assessment of Glasgow coma scale (GCS)
  • treatment depends on the type of fracture
    • linear: no specific treatment
    • depressed: may require neurosurgical intervention to prevent further brain injury
    • base of skull fracture: may be unstable and require expert

Imaging

• role of imaging
  • diagnosis of fracture
    • skull x-rays are still performed but are being used less and less
    • CT head is the first line investigation
  • assessment for intracranial injury, e.g. hemorrhage
    • assessment of the need for imaging using a clinical scoring system
      • NICE guidance
      • Canadian CT head rule
  • assessment of fracture to guide risk stratification and management
• radiographic features
  • CT
    • best method for looking for bony injury
    • best test for looking at extra-axial collection or brain injury
    • allows assessment for other signs, e.g. pneumocephalus
    • review on different windows (brain, blood, bone)
    • 3D reconstruction