III. Signs: Basilar Skull Fracture
- Ear findings
- Otorrhea
- Hemotympanum
- Battle Sign (delayed by hours to 24 hours)
- Mastoid echymosis
- Racoon Eyes (occurs soon after injury)
- Periorbital Ecchymosis
- Cranial Nerve deficits
- Double Ring Sign (on bedding, paper)
- CSF Leakage will form appearance of watermelon in cross section
- Large Inner ring of pink, bloody CSF fluid
- Small outer ring of clear CSF fluid (analogous to the rind of a watermelon)
- Beta-2 Transferrin
- Preferred test for CSF Leak
- Bedside Glucose of draining fluid
- CSF fluid will have bedside Glucose >30 mg/dl
IV. Imaging: CT Head (skull films may show some of these findings)
- Identifying Fracture Site and CSF Leaks on CT Head
- Maxillofacial CT (indicated if facial Trauma)
- CT Bone Windows show Fracture lines best
- CT bone reconstruction algorithms
- CT cisternogram
- Iodinated contrast injected into lumbar thecal sac
- Enhances intracranial CSF spaces and identifies CSF Leaks
- Anticipate contrast to fill all CSF spaces (e.g. subarachnoid space, ventricles)
- Contrast seen outside of CSF spaces suggests CSF Leak
- Prone Positioning increases CSF Leak
- Perioperative Flourescein injection into lumbar thecal sac
- Helps identify CSF Leak during surgery
-
Temporal Bone
Fracture
- Subtle CT findings
- Evaluate closely for Epidural Hematoma (from middle meningeal artery injury)
- Images
- Basilar Skull Fracture (CT may be normal)
- Intracranial air (Pneumocephalus)
- Sphenoid Sinus or Frontal Sinus air fluid level
- Cribiform PlateFracture
V. Precautions
- Skull Fractures imply injury from a significant force
- Skull Fractures increase the risk of intracranial Hematomas by 400 fold
VI. Approach
- Temporal Skull Fracture
- Monitor closely for Epidural Hematoma (from middle meningeal artery injury)
- Open or depressed Skull Fracture (>1 bone table width or more than thickness of adjacent skull)
- Risk of intracranial Hematoma, Brain Contusion and Meningitis
- Urgent neurosurgery Consultation
- Antibiotics
- Occipital Skull Fracture
- Associated complications
- Subarachnoid Hemorrhage
- Contre-coup injury
- Posterior fossa Hematoma
- Cranial Nerve Injury
- Associated complications
- Stellate or complex Fractures
- Consider Child Abuse
- Linear non-depressed Fracture
- No specific management
- CSF Leakage (e.g. Basilar Skull Fracture)
- Beta-2 Transferrin test
- See Double Ring Sign above
- No reduction in CSF Leak-related Meningitis with prophylactic Antibiotics
- CSF Leakage typically resolves within 7 days
- Neurosurgery indicated in high volume CSF Leaks and persistent CSF Leak >7 days
- Pneumocephalus
- CT Head Finding suggesting open Skull Fracture or facial sinus communication (e.g. frontal, sphenoid, ethmoid)
- May be associated with Cerebrospinal Fluid Leak (e.g. CSF Rhinorrhea)
VII. References
- (2008) ATLS, American College of Surgeons, p. 138, 148
- Broder (2018) Crit Dexc Emerg Med 32(9): 14-5
- Gouch (2013) Head Trauma, EM Bootcamp, CEME
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NCI) | Discharge of cerebrospinal fluid through the ear structures. |
| Definition (MSH) | Discharge of cerebrospinal fluid through the external auditory meatus or through the eustachian tube into the nasopharynx. This is usually associated with CRANIOCEREBRAL TRAUMA (e.g., SKULL FRACTURE involving the TEMPORAL BONE;), NEUROSURGICAL PROCEDURES; or other conditions, but may rarely occur spontaneously. (From Am J Otol 1995 Nov;16(6):765-71) |
| Concepts | Disease or Syndrome (T047) |
| MSH | D002558 |
| ICD9 | 388.61 |
| SnomedCT | 68382005 |
| English | Cerebrospinal Fluid Otorrhea, Cerebrospinal Fluid Otorrheas, Cerebrospinal Otorrhea, Otorrhea, Cerebrospinal, Otorrhea, Cerebrospinal Fluid, CSF-Cerebrospnl fluid otorhoea, CSF OTORRHEA, cerebrospinal fluid otorrhea, cerebrospinal fluid otorrhea (diagnosis), CSF otorrhea, Cerebrosp fluid otorrhea, Cerebrospinal Fluid Otorrhea [Disease/Finding], Cerebrospinal fluid otorrhea, CSF - Cerebrospinal otorrhea, CSF - Cerebrospinal otorrhoea, Cerebrospinal fluid otorrhoea, Cerebrospinal otorrhea, Cerebrospinal otorrhoea, CSF - Cerebrospinal fluid otorrhea, CSF - Cerebrospinal fluid otorrhoea, Cerebrospinal fluid otorrhea (disorder), cerebrospinal; otorrhea, otorrhea; cerebrospinal |
| Swedish | Cerebrospinal otorre |
| Czech | mok mozkomíšní - výtok z ucha, cerebrospinální otorea, mozkomíšní mok - otorea, Ušní likvorea, Otorhea mozkomíšního moku |
| Finnish | Korvan aivo-selkäydinnestevuoto |
| Russian | OTOREIA SPINNOMOZGOVOI ZHIDKOSTI, SPINNOMOZGOVOI ZHIDKOSTI OTOREIA, OTOREIA TSEREBROSPINAL'NAIA, ОТОРЕЯ СПИННОМОЗГОВОЙ ЖИДКОСТИ, ОТОРЕЯ ЦЕРЕБРОСПИНАЛЬНАЯ, СПИННОМОЗГОВОЙ ЖИДКОСТИ ОТОРЕЯ |
| Spanish | Otorrea de Líquido Cefalorraquídeo, Otorrea de líquido cefalorraquídeo, Otorrea Cefalorraquídea, otorrea de líquido cefalorraquídeo (trastorno), otorrea de líquido cefalorraquídeo, Otorrea del Líquido Cerebroespinal |
| Italian | Otorrea cerebrospinale, Otorrea di liquido cerebrospinale, Otorrea del liquido cerebrospinale, Otorrea del fluido cerebrospinale |
| Polish | Wyciek z ucha płynu mózgowo-rdzeniowego, Płynotok mózgowo-rdzeniowy uszny |
| Japanese | 耳性髄液漏, 髄液耳漏, ｽﾞｲｴｷｼﾞﾛｳ, 脳脊髄液耳漏, 髄液漏-耳性 |
| Norwegian | Lekkasje av cerebrospinalvæske fra øret, Cerebrospinalvæskeotoré, Cerebrospinal otoré |
| Portuguese | Otorreia de Líquido Cefalorraquidiano, Otorreia Liquórica, Otorreia de líquido cefalorraquidiano, Otorráquia |
| Dutch | liquor otorrhoea, otorroe van cerebrospinaal vocht, cerebrospinaal; otorroe, otorroe; cerebrospinaal, Liquorrhoe, Otorrhoe, Otorrhoea cerebrospinale |
| French | Otorrhée du liquide céphalorachidien, Otorrhée cérébrospinale, Otorrhée cérébro-spinale, Otorrhée de LCR, Otorrhée de LCS, Otorrhée de liquide céphalo-rachidien, Otorrhée de liquide céphalorachidien, Otorrhée de liquide cérébrospinal |
| German | Liquor cerebrospinalis-Otorrhoe, Otoliquorrhoe, Zerebrospinale Otorrhoe |
| Hungarian | Liquorfolyás a fülből |
Ontology: Cerebrospinal Fluid Rhinorrhea (C0007815)
| Definition (NCI) | Discharge of cerebrospinal fluid through the nose. |
| Definition (MSH) | Discharge of cerebrospinal fluid through the nose. Common etiologies include trauma, neoplasms, and prior surgery, although the condition may occur spontaneously. (Otolaryngol Head Neck Surg 1997 Apr;116(4):442-9) |
| Concepts | Disease or Syndrome (T047) |
| MSH | D002559 |
| ICD9 | 349.81 |
| SnomedCT | 85638002 |
| English | Cerebrospinal Fluid Rhinorrhea, Cerebrospinal Fluid Rhinorrheas, Cerebrospinal Rhinorrhea, Cerebrospinal Rhinorrheas, Rhinorrheas, Cerebrospinal, Rhinorrheas, Cerebrospinal Fluid, Rhinorrhea, Cerebrospinal, Rhinorrhea, Cerebrospinal Fluid, CSF - Cerebrospinal rhinorrho, Cerebrospinal fluid rhinorrh., cerebrospinal fluid rhinorrhea (diagnosis), cerebrospinal fluid rhinorrhea, CSF rhinorrhea, Cerebrospinal Fluid Rhinorrhea [Disease/Finding], cerebrospinal rhinorrhea, cerebrospinal fluid rhinorrhoea, CSF Rhinorrheas, CSF Rhinorrhea, Rhinorrhea, CSF, Rhinorrheas, CSF, Cerebrospinal fluid rhinorrhea, CSF - Cerebrospinal rhinorrhea, CSF - Cerebrospinal rhinorrhoea, Cerebrospinal fluid rhinorrhoea, Cerebrospinal rhinorrhea, Cerebrospinal rhinorrhoea, Cerebrospinal fluid rhinorrhea (disorder), cerebrospinal; rhinorrhea, rhinorrhea; cerebrospinal |
| Swedish | Cerebrospinal rinorre |
| Czech | cerebrospinální rinorea, mozkomíšní mok - výtok z nosu, likvorea nazální, mozkomíšní mok - rinorea, Likvorová rinorea |
| Finnish | Nenän aivo-selkäydinnestevuoto |
| Russian | RINOREIA TSEREBROSPINAL'NAIA, SPINNOMOZGOVOI ZHIDKOSTI RINOREIA, RINOREIA SPINNOMOZGOVOI ZHIDKOSTI, РИНОРЕЯ СПИННОМОЗГОВОЙ ЖИДКОСТИ, РИНОРЕЯ ЦЕРЕБРОСПИНАЛЬНАЯ, СПИННОМОЗГОВОЙ ЖИДКОСТИ РИНОРЕЯ |
| Polish | Płynotok mózgowo-rdzeniowy nosowy, Wyciek z nosa płynu mózgowo-rdzeniowego |
| Japanese | 髄液鼻漏, 髄液性鼻漏, ｽﾞｲｴｷﾋﾞﾛｳ, 脳脊髄液鼻漏, 髄液鼻瘻, 鼻性髄液漏, 髄液性鼻瘻, 鼻髄液漏 |
| Norwegian | Cerebrospinal rhinoré |
| Portuguese | Rinorreia Cefalorraquidiana, Rinorreia de Líquido Cefalorraquidiano, Rinorráquia, Rinorreia Liquórica, Rinorreia de Líquido Cefalorraquiano |
| Dutch | liquor rhinorroe, cerebrospinaal; rinorroe, rinorroe; cerebrospinaal, Cerebrospinale rhinorroe, Rhinorrhoea cerebrospinalis |
| French | Rhinorrhée du liquide céphalo-rachidien, Rhinorrhée cérébrospinale, Rhinorrhée cérébro-spinale, Rhinorrhée de LCR, Rhinorrhée de LCS, Rhinorrhée de liquide céphalo-rachidien, Rhinorrhée de liquide céphalorachidien, Rhinorrhée de liquide cérébrospinal |
| German | Rhinorrhoe der Zerebrospinalfluessigkeit, Rhinoliquorrhoe, Zerebrospinale Rhinorrhoe |
| Hungarian | Liquorfolyás orrból |
| Italian | Rinorrea del liquido cerebrospinale, Rinorrea cerebrospinale |
| Spanish | Rinorrea de líquido cefalorraquídeo, rinorrea de líquido cefalorraquídeo (trastorno), rinorrea de líquido cefalorraquídeo, Rinorrea Cerebroespinal, Rinorrea de Líquido Cefalorraquídeo |
Ontology: Cerebrospinal fluid leak (C0023182)
| Definition (NCI) | The loss of cerebrospinal fluid into the surrounding tissues. |
| Definition (NCI_CTCAE) | A disorder characterized by loss of cerebrospinal fluid into the surrounding tissues. |
| Concepts | Pathologic Function (T046) |
| ICD10 | G96.0 |
| SnomedCT | 73965003, 230744007 |
| English | Cerebrospinal Fluid Leakage, Cerebrospinal fluid leak, Leakage of cerebrospinal fluid, CSF leakage, leakage cerebrospinal fluid, csf leakage, cerebrospinal fluid leak, cerebrospinal fluid leakage, cerebrospinal fluid leaks, LEAKAGE OF CEREBROSPINAL FLUID, FLUID, LEAKAGE OF CEREBROSPINAL, CEREBROSPINAL FLUID LEAKAGE, Cerebrospinal fluid leakage, CSF - Cerebrospinal fluid leak, Cerebrospinal fluid leak (disorder), Cerebrospinal fluid leakage (morphologic abnormality), cerebrospinal fluid; cerebrospinal, leak, cerebrospinal fluid; leakage, leak; cerebrospinal fluid |
| German | Austritt von Liquor cerebrospinalis, CSF Austritt, Austritt von Liquor |
| Korean | 뇌척수액 누출 |
| Czech | Vytékaní mozkomíšního moku, CSF únik, Únik mozkomíšního moku |
| Dutch | lek van cerebrospinaal vocht, CSV lek, lek; liquor cerebrospinalis, liquor; cerebrospinalis, lek, liquor; lekkage, Liquorlekkage, cerebrospinaal vocht lek |
| French | Fuite du liquide céphalorachidien, Fuite de LCR, Fuite de liquide céphalorachidien |
| Hungarian | Liquor szivárgása, Liquor szivárgás |
| Italian | Perdita di liquido cerebrospinale |
| Japanese | 脳脊髄液漏, ﾉｳｾｷｽﾞｲｴｷﾛｳ |
| Portuguese | Fuga de LCR, Fuga de líquido cefalorraquidiano |
| Spanish | Fugas de LCR, filtración de líquido cefalorraquídeo (anomalía morfológica), filtración de líquido cefalorraquídeo (trastorno), filtración de líquido cefalorraquídeo, pérdida de líquido cefalorraquídeo, Fugas de líquido cefalorraquídeo |
Ontology: Pneumocephalus (C0032268)
| Definition (MSH) | Presence of air or gas within the intracranial cavity (e.g., epidural space, subdural space, intracerebral, etc.) which may result from traumatic injuries, fistulous tract formation, erosions of the skull from NEOPLASMS or infection, NEUROSURGICAL PROCEDURES, and other conditions. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D011007 |
| SnomedCT | 14415006 |
| English | Pneumocephalus, Airocele, Cranial, Cranial Airocele, Airoceles, Cranial, Cranial Airoceles, Cranial Pneumocyst, Pneumocyst, Cranial, Cranial Pneumocysts, Pneumocysts, Cranial, Gas, Intracranial, Intracranial Gas, Pneumocephalus [Disease/Finding], pneumocephalus, Airocoele, Airocele, Pneumocephalus (disorder) |
| Swedish | Pneumocefalus |
| Japanese | ｷﾉｳﾀｲ, 頭蓋内気腫, 気脳体, 気脳症, 気脳 |
| Czech | pneumocefalus, Pneumocefalus |
| Finnish | Pneumokefalus |
| Russian | PNEVMOTSEFALIIA, ПНЕВМОЦЕФАЛИЯ |
| Italian | Gas intracranico, Pneumocefalo |
| Polish | Odma czaszkowa |
| Hungarian | Pneumocephalus |
| Norwegian | Intrakranial luft, Pneumocefalus, Pneumocephalus |
| Portuguese | Pneumocéfalo, Ar Intracraniano, Pneumocefalia, Pneumocisto Craniano |
| Spanish | neumocéfalo (trastorno), neumocéfalo, Neumocefalia, Gas Intracraneal, Neumocéfalo, Pneumoquiste Craneal |
| Dutch | pneumocefalus, Craniale pneumocyste, Encefalie, pneumo-, Intracraniale lucht, Pneumo-encefalie |
| German | Pneumozephalus, Intrakranielle Gasansammlung, Kranielle Pneumozele, Kranielle Pneumatozele, Pneumatozephalus |
| French | Pneumocéphalie, Pneumo-encéphale, Pneumatocèle intracrânienne, Pneumocéphale |
Ontology: Skull Fractures (C0037304)
| Definition (NCI) | A traumatic or pathologic injury to the bones of the skull in which the continuity of the bones of the skull is broken. |
| Definition (MSH) | Fractures of the skull which may result from penetrating or nonpenetrating head injuries or rarely BONE DISEASES (see also FRACTURES, SPONTANEOUS). Skull fractures may be classified by location (e.g., SKULL FRACTURE, BASILAR), radiographic appearance (e.g., linear), or based upon cranial integrity (e.g., SKULL FRACTURE, DEPRESSED). |
| Concepts | Injury or Poisoning (T037) |
| MSH | D012887 |
| ICD9 | 800-804.99 |
| SnomedCT | 157175003, 207883002, 157170008, 207841007, 269059005, 71642004 |
| English | Fractures, Skull, Skull Fractures, Fracture, Skull, Fracture of skull NOS, Skull fracture NOS, Skull Fracture, skull fracture, skull fracture (diagnosis), Skull Fractures [Disease/Finding], fractures of the skull, skull fractures, Fracture;skull, Skull fractures, Fracture of skull NOS (disorder), Skull fracture NOS (disorder), Skull fracture (disorder), Skull--Fractures, SKULL FRACTURE, Fracture of Skull, FRACTURE, SKULL, Skull fracture, Fracture of skull, Fractured skull, Fracture of skull (disorder), fracture; skull, skull; fracture, Fracture of skull, NOS, FRACTURE OF SKULL, fractured skull |
| Italian | Frattura del cranio, Frattura del cranio NAS, Fratture craniche, Fratture del cranio |
| Dutch | schedelbreuk NAO, fractuur; schedel, schedel; fractuur, schedelbreuk, Fracturen, schedel-, Fractuur, schedel-, Schedelfracturen, Schedelfractuur |
| French | Fracture du crâne SAI, Fractures de la boite crânienne, Fracture du crâne, Fractures crâniennes, Fractures du crâne, Fractures de la boîte crânienne |
| German | Schaedelbruch NNB, Schaedelbruch, Schädelfrakturen |
| Portuguese | Fractura do crânio NE, Fractura do crânio, Fraturas Cranianas |
| Spanish | Fractura de cráneo NEOM, fractura craneal, SAI, fractura de cráneo, SAI, fractura craneal, SAI (trastorno), fractura de cráneo, SAI (trastorno), Skull fracture NOS, fractura craneal, fractura de cráneo (trastorno), fractura de cráneo, Fractura de cráneo, Fracturas Craneales |
| Japanese | 頭蓋骨骨折ＮＯＳ, 頭蓋骨骨折, 頭蓋骨折(ズガイコッセツ), 頭蓋骨骨折(ズガイコツコッセツ), 骨折-頭蓋, 頭蓋骨折, ﾄｳｶﾞｲｺﾂｺｯｾﾂNOS, ﾄｳｶﾞｲｺﾂｺｯｾﾂ |
| Swedish | Skallfrakturer |
| Finnish | Kallonmurtumat |
| Russian | CHEREPA PERELOMY, ЧЕРЕПА ПЕРЕЛОМЫ |
| Czech | Zlomenina lebky NOS, Zlomenina lebky, fraktury lebky, zlomeniny lebky, lebka - fraktury |
| Croatian | LUBANJA, FRAKTURE |
| Polish | Złamania czaszki |
| Hungarian | Koponyatörés, Koponyatörés k.m.n. |
| Norwegian | Hodeskallebrudd, Kraniebrudd, Brudd på hodeskallen, Skallebrudd |
Ontology: Battle Sign (C0741451)
| Concepts | Sign or Symptom (T184) |
| MSH | D020205 |
| Portuguese | Sinal de Battle |
| Spanish | Signo de Battle |
| French | Signe de Battle |
| German | Battle-Zeichen |
| English | Battle's Sign, Battles Sign, Sign, Battle, Sign, Battle's, battle signs, battle sign, battles sign, battle's sign, Battle Sign |
| Czech | prokrvácení v oblasti processus mastoideus, battle sign |
| Norwegian | Battles tegn |
| Dutch | Teken van Battle |
Ontology: Skull Fracture, Basilar (C0748830)
| Definition (MSH) | Fractures which extend through the base of the SKULL, usually involving the PETROUS BONE. Battle's sign (characterized by skin discoloration due to extravasation of blood into the subcutaneous tissue behind the ear and over the mastoid process), CRANIAL NEUROPATHIES, TRAUMATIC; CAROTID-CAVERNOUS SINUS FISTULA; and CEREBROSPINAL FLUID OTORRHEA are relatively frequent sequelae of this condition. (Adams et al., Principles of Neurology, 6th ed, p876) |
| Concepts | Injury or Poisoning (T037) |
| MSH | D020205 |
| ICD9 | 801 |
| ICD10 | S02.1 |
| SnomedCT | 207752008, 207715008, 157173005, 24063002 |
| English | Fracture of base of skull NOS, fracture of base of skull (diagnosis), basilar skull fracture, fracture of base of skull, Skull fractured base, Basilar Skull Fracture, Basilar Skull Fractures, Fracture, Basilar Skull, Fractures, Basilar Skull, Skull Fracture, Basilar, Skull Fractures, Basilar, Skull Fracture, Basilar [Disease/Finding], base of skull fracture, Fracture;skull (base), skull base fracture, fracture base of skull, fracture of skull base, base fractures skull, basilar skull fractures, Fracture of base of skull NOS (disorder), Skull base fracture (disorder), Fracture of base of skull, Skull base fracture, Fracture of base of skull (disorder), base of skull; fracture, fracture; base of skull, fracture; skull, base, skull; fracture, base, Fracture of base of skull, NOS, fractured base of skull, Fracture;base of skull |
| Italian | Frattura della base cranica, Frattura della base del cranio |
| Dutch | schedelbasisfractuur, fractuur; schedel, basis, fractuur; schedelbasis, schedel; fractuur, basis, schedelbasis; fractuur, schedelbasisbreuk, Fractuur, schedelbasis-, Schedelbasisfractuur |
| German | Fraktur der Schaedelbasis, Schaedelbasisfraktur, Basiläre Schädelfrakturen, Schädelfrakturen, basiläre |
| Portuguese | Fractura fechada da base do crânio, Fratura da Base do Crânio, Fratura Basilar do Crânio, Fratura Craniana Basilar, Crânio fracturado na base |
| Spanish | Fractura Basilar del Cráneo, fractura de la base del cráneo (trastorno), fractura de la base de cráneo, SAI (trastorno), fractura de la base de cráneo, SAI, fractura de base de cráneo, fractura de la base del cráneo, fractura de base de cráneo (trastorno), Fractura de la Base del Cráneo, Fractura de la base del cráneo, Fractura Craneal Basilar |
| Japanese | 頭蓋底の骨折, バトル徴候, バットル徴候, 頭蓋底骨折, Battle徴候, ﾄｳｶﾞｲﾃｲﾉｺｯｾﾂ, ﾄｳｶﾞｲﾃｲｺｯｾﾂ |
| Swedish | Skallbasfraktur |
| Finnish | Basilaarinen kallonmurtuma |
| Russian | OSNOVANIIA CHEREPA PERELOM, CHEREPA OSNOVANIIA PERELOMY, ОСНОВАНИЯ ЧЕРЕПА ПЕРЕЛОМ, ЧЕРЕПА ОСНОВАНИЯ ПЕРЕЛОМЫ |
| Czech | Zlomenina baze lebeční, Zlomenina baze lební, zlomeniny spodiny lebeční, zlomeniny baze lební, fraktury baze lební, lebka - fraktury baze lební |
| Korean | 머리뼈바닥의 골절 |
| Polish | Złamanie podstawy czaszki |
| Hungarian | Koponyaalapi törés |
| Norwegian | Brudd på skallebasis |
| French | Fracture de la base du crâne, Fractures de la base du crâne |
