Skull Fracture


Skull Fracture, Basilar Skull Fracture, Basal Skull Fracture, Battle Sign, Battle's Sign, Racoon Eyes, Double Ring Sign

  • 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
  • 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
  • Precautions
  1. Skull Fractures imply injury from a significant force
  2. Skull Fractures increase the risk of intracranial hematomas by 400 fold
  • 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
  • References
  1. (2008) ATLS, American College of Surgeons, p. 138, 148
  2. Gouch (2013) Head Trauma, EM Bootcamp, CEME