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)
- 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)
-
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
- 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
- Basilar Skull Fracture
- CSF Leakage
- See Double Ring Sign above
- CSF leakage typically resolves within 1 week
- No reduction in CSF leak-related Meningitis with prophylactic antibiotics
- CSF Leakage
VII. References
- (2008) ATLS, American College of Surgeons, p. 138, 148
- Gouch (2013) Head Trauma, EM Bootcamp, CEME
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| 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 |
