III. Signs: Basilar Skull Fracture

  1. Ear findings
    1. Otorrhea
    2. Hemotympanum
  2. Battle Sign (delayed by hours to 24 hours)
    1. Mastoid echymosis
  3. Racoon Eyes (occurs soon after injury)
    1. Periorbital Ecchymosis
  4. Cranial Nerve deficits
    1. Cranial Nerve V (Trigeminal Nerve)
    2. Cranial Nerve VI (Abducens Nerve)
    3. Cranial Nerve VII (Facial Nerve)
    4. Cranial Nerve VIII (Acoustic Nerve)
  5. Double Ring Sign (on bedding, paper)
    1. CSF Leakage will form appearance of watermelon in cross section
    2. Large Inner ring of pink, bloody CSF fluid
    3. Small outer ring of clear CSF fluid (analogous to the rind of a watermelon)
  6. Bedside Glucose of draining fluid
    1. CSF fluid will have bedside Glucose >30 mg/dl

IV. Imaging: CT Head (skull films may show some of these findings)

  1. Identifying Fracture Site and CSF Leaks on CT Head
    1. Maxillofacial CT (indicated if facial Trauma)
    2. CT Bone Windows show Fracture lines best
    3. CT bone reconstruction algorithms
    4. CT cisternogram
      1. Iodinated contrast injected into lumbar thecal sac
      2. Enhances intracranial CSF spaces and identifies CSF Leaks
      3. Anticipate contrast to fill all CSF spaces (e.g. subarachnoid space, ventricles)
        1. Contrast seen outside of CSF spaces suggests CSF Leak
    5. Prone positioning increases CSF Leak
    6. Perioperative Flourescein injection into lumbar thecal sac
      1. Helps identify CSF Leak during surgery
  2. Temporal Bone Fracture
    1. Subtle CT findings
    2. Evaluate closely for Epidural Hematoma (from middle meningeal artery injury)
    3. Images
      1. middleMeningealArtery.jpg
  3. Basilar Skull Fracture (CT may be normal)
    1. Intracranial air (Pneumocephalus)
    2. Sphenoid Sinus or Frontal Sinus air fluid level
    3. Cribiform PlateFracture

V. Precautions

  1. Skull Fractures imply injury from a significant force
  2. Skull Fractures increase the risk of intracranial hematomas by 400 fold

VI. Approach

  1. Temporal Skull Fracture
    1. Monitor closely for Epidural Hematoma (from middle meningeal artery injury)
  2. Open or depressed Skull Fracture (>1 bone table width or more than thickness of adjacent skull)
    1. Risk of intracranial hematoma, Brain Contusion and Meningitis
    2. Urgent neurosurgery Consultation
    3. Antibiotics
  3. Occipital Skull Fracture
    1. Associated complications
      1. Subarachnoid Hemorrhage
      2. Contre-coup injury
      3. Posterior fossa hematoma
      4. Cranial Nerve Injury
  4. Stellate or complex Fractures
    1. Consider Child Abuse
  5. Linear non-depressed Fracture
    1. No specific management
  6. CSF Leakage (e.g. Basilar Skull Fracture)
    1. See Double Ring Sign above
    2. No reduction in CSF Leak-related Meningitis with prophylactic antibiotics
    3. CSF Leakage typically resolves within 7 days
      1. Neurosurgery indicated in high volume CSF Leaks and persistent CSF Leak >7 days
  7. Pneumocephalus
    1. CT Head Finding suggesting open Skull Fracture or facial sinus communication (e.g. frontal, sphenoid, ethmoid)
    2. May be associated with Cerebrospinal Fluid Leak (e.g. CSF Rhinorrhea)

VII. References

  1. (2008) ATLS, American College of Surgeons, p. 138, 148
  2. Broder (2018) Crit Dexc Emerg Med 32(9): 14-5
  3. Gouch (2013) Head Trauma, EM Bootcamp, CEME

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Cerebrospinal Fluid Otorrhea (C0007814)

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, ズイエキジロウ, 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, ズイエキビロウ, 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, ノウセキズイエキロウ
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, トウガイコツコッセツNOS, トウガイコツコッセツ
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, トウガイテイノコッセツ, トウガイテイコッセツ
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