Skull Fracture

Aka: Skull Fracture, Basilar Skull Fracture, Basal Skull Fracture, Battle Sign, Battle's Sign, Racoon Eyes, Double Ring Sign, Traumatic CSF Leak, Traumatic Cerebrospinal Fluid Leak, Cerebrospinal Fluid Leak, CSF Leak, Pneumocephalus, Cerebrospinal Fluid Otorrhea, CSF Otorrhea, Cerebrospinal Fluid Rhinorrhea, CSF Rhinorrhea

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II. Causes

  1. Head Injury
  2. Skull Fracture from Birth Trauma
  3. Child Abuse

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. Beta-2 Transferrin
    1. Preferred test for CSF Leak
  7. 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. Beta-2 Transferrin test
    2. See Double Ring Sign above
    3. No reduction in CSF Leak-related Meningitis with prophylactic Antibiotics
    4. 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

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