This is a basic article for medical students and other non-radiologists

Skull fractures usually occur following significant head injury and may herald underlying neurological pathology.

Reference article

This is a summary article; read more in our article on skull fractures.

Summary

• anatomy

  • cranial vault

  • base of the skull

• epidemiology

  • accurate incidence and prevalence unknown

  • 1.3 million traumatic brain injuries per year in the USA ¹

    • estimated that 1/3 will have a skull fracture

• presentation

  • head injury following impact trauma, e.g. fall, RTC

  • symptoms associated with underlying injury

    • extradural hemorrhage

    • subdural hemorrhage

    • subarachnoid hemorrhage

  • there may be an associated base of skull injury

    • CSF rhinorrhea

    • Battle sign (bruising over mastoid process)

    • raccoon eyes

• pathophysiology

  • mechanism

    • children and elderly: simple fall

    • adults: usually high-energy impact trauma, e.g. RTC

  • different types of fractures

    • linear

    • depressed skull fracture

    • base of skull fracture

    • ping pong fracture

    • growing skull fracture

    • diastatic (widening suture lines in childhood)

  • associations

    • bone fragments under the fracture

    • other penetrating injuries

    • intracranial hemorrhage

• treatment

  • head injury patients should be treated following ATLS (or similar)

    • C-spine control and ABCDE

    • assessment of Glasgow coma scale (GCS)

  • treatment depends on the type of fracture

    • linear: no specific treatment

    • depressed: may require neurosurgical intervention to prevent further brain injury

    • base of skull fracture: may be unstable and require expert

Imaging

• role of imaging

  • diagnosis of fracture

    • skull x-rays are still performed but are being used less and less

    • CT head is the first line investigation

  • assessment for intracranial injury, e.g. hemorrhage

    • assessment of the need for imaging using a clinical scoring system

      • NICE guidance

      • Canadian CT head rule

  • assessment of fracture to guide risk stratification and management

• radiographic features

  • CT

    • best method for looking for bony injury

    • best test for looking at extra-axial collection or brain injury

    • allows assessment for other signs, e.g. pneumocephalus

    • review on different windows (brain, blood, bone)

    • 3D reconstruction