History and exam
Key diagnostic factors
uncommon
open fracture
Laceration or wound to skin/soft tissue with exposed fractured bone or visible bone fragments is suggestive of skull fracture.
palpable discrepancy in bone contour
"Step-off" or a palpable discrepancy in bone contour is suggestive of a fracture.
Battle sign
periorbital ecchymosis
bloody otorrhea
cerebrospinal fluid rhinorrhea
Most often associated with fractures of the anterior cranial fossa.[1]
Confirmation requires beta-2 transferrin test.
facial paralysis, nystagmus, or paresthesia
Consequence of cranial nerve injury causing facial paralysis or nystagmus (VII) or paresthesia (V); associated with basilar skull fractures.
Other diagnostic factors
common
evidence of trauma
Includes soft-tissue swelling, hematomas, crepitus, lacerations, and tenderness.
Not specific for skull fracture, although the presence of cranial hematomas is more suggestive of a skull fracture in children than in adults.[56] Absence of these features does not exclude fracture.
uncommon
cranial pain or headache
Nonspecific symptom. Occipital skull fractures, crossing the transverse venous sinus, can cause venous sinus thrombosis, which in turn will cause raised intracranial pressure. In an awake and alert patient, this may present as intractable headaches with nausea and vomiting.[57]
nausea
Nonspecific symptom. Occipital skull fractures, crossing the transverse venous sinus, can cause venous sinus thrombosis, which in turn will cause raised intracranial pressure. In an awake and alert patient, this may present as intractable headaches with nausea and vomiting.[57]
altered mental state/loss of consciousness
Loss of consciousness is most commonly related to underlying associated intracranial injury, and is rare in isolated skull fractures.
The patient's neurologic status should be assessed at initial presentation and subsequently monitored to help guide management decisions. The Glasgow Coma Scale (GCS) is commonly used to assess any associated traumatic brain injury.[34]
GCS has 3 components: best eye response (E), best verbal response (V), and best motor response (M).
A GCS of 13 to 15 is associated with mild brain injury, a GCS of 9 to 12 is associated with moderate brain injury, and a GCS of <8 is associated with severe brain injury.
abnormal pupillary reflexes
If present, can suggest herniation or brainstem injury.
hearing loss
Basilar skull fractures may cause facial (VII) nerve injury with sensorineural hearing loss. Conductive hearing loss may also present early (<3 weeks) due to hemotympanum with temporal bone fractures, or later (>6 weeks) with longitudinal temporal bone fracture with disruption of ossicular chain.
Risk factors
strong
fall from height
motor vehicle accident
assault resulting in head trauma
A common cause of fractures, accounting for up to 30% of skull fractures in adults.[11]
gunshots to the head
An uncommon cause of skull fracture, but when present a gunshot wound to the head has a high chance of causing a fracture. [Figure caption and citation for the preceding image starts]: Transcranial gunshot woundFrom the teaching collection of Demetrios Demetriades; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Gunshot wound with comminuted elevated fracture and pneumocephalusFrom the teaching collection of Demetrios Demetriades; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Gunshot wound with perpendicular blowout fractureFrom the teaching collection of Demetrios Demetriades; used with permission [Citation ends].
Use of this content is subject to our disclaimer