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. Temporal Bone Fracture
    1. Subtle CT findings
    2. Evaluate closely for Epidural Hematoma (from middle meningeal artery injury)
    3. Images
      1. middleMeningealArtery.jpg
  2. Basilar Skull Fracture (CT may be normal)
    1. Intracranial air
    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. Basilar Skull Fracture
    1. CSF Leakage
      1. See Double Ring Sign above
      2. CSF leakage typically resolves within 1 week
      3. No reduction in CSF leak-related Meningitis with prophylactic antibiotics

VII. References

  1. (2008) ATLS, American College of Surgeons, p. 138, 148
  2. Gouch (2013) Head Trauma, EM Bootcamp, CEME

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Related Studies

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
Czech Zlomenina lebky NOS, Zlomenina lebky, fraktury lebky, zlomeniny lebky, lebka - fraktury
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
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