Skull fractures in adults
- William G Heegaard, MD, MPH
William G Heegaard, MD, MPH
- Professor of Emergency Medicine
- University of Minnesota School of Medicine
- Michelle H Biros, MD
Michelle H Biros, MD
- Professor of Emergency Medicine
- University of Minnesota Medical School
- Section Editor
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Skull fractures have plagued humankind throughout history . They occur when forces striking the head exceed the mechanical integrity of the calvarium. Significant skull fractures are often accompanied by moderate or severe intracranial injury and extracranial injuries associated with high-energy trauma, such as cervical and other spine fractures and thoracoabdominal injuries [2-9].
The epidemiology, mechanisms, clinical presentation, associated complications, and initial management of skull fractures in adults are reviewed here. Skull fractures in children and intracranial injuries are discussed separately. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management" and "Intracranial epidural hematoma in adults" and "Subdural hematoma in adults: Etiology, clinical features, and diagnosis" and "Nonaneurysmal subarachnoid hemorrhage" and "Acute mild traumatic brain injury (concussion) in adults".)
The incidence of skull fractures among head injured adults who present to emergency departments (ED) is unknown. The parietal bone is most frequently fractured, followed by the temporal, occipital, and frontal bones . Linear fractures are the most common, followed by depressed and basilar skull fractures. (See 'Definition and presentation of skull fracture types' below.)
Much of the data on skull fractures in adults come from studies of traumatic brain injury (TBI). Each year, approximately 2.8 million people sustain head injuries in the United States alone, resulting in 2.5 million undergoing emergency evaluation .
According to one retrospective study of 207 head-injured patients, 37 percent of those with associated intracranial pathology sustained a linear skull fracture . According to another retrospective study of 2254 cases of head trauma from assault, approximately one-third sustained a skull fracture .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Hippocratic Writings, Lloyd G (Ed), Penguin Group, London 1978.
- Britt PM, Heiseman JE. Imaging evaluation. In: Head Injury, 4th, Cooper PR, Golfinos JG (Eds), McGraw-Hill, New York 2000. p.63.
- Chan KH, Mann KS, Yue CP, et al. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J Neurosurg 1990; 72:189.
- Hung CC, Chiu WT, Lee LS, et al. Risk factors predicting surgically significant intracranial hematomas in patients with head injuries. J Formos Med Assoc 1996; 95:294.
- Macpherson BC, MacPherson P, Jennett B. CT evidence of intracranial contusion and haematoma in relation to the presence, site and type of skull fracture. Clin Radiol 1990; 42:321.
- Hsiao KY, Hsiao CT, Weng HH, et al. Factors predicting mortality in victims of blunt trauma brain injury in emergency department settings. Emerg Med J 2008; 25:670.
- Butcher I, McHugh GS, Lu J, et al. Prognostic value of cause of injury in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007; 24:281.
- Carson HJ. Brain trauma in head injuries presenting with and without concurrent skull fractures. J Forensic Leg Med 2009; 16:115.
- Muñoz-Sánchez MA, Murillo-Cabezas F, Cayuela-Domínguez A, et al. Skull fracture, with or without clinical signs, in mTBI is an independent risk marker for neurosurgically relevant intracranial lesion: a cohort study. Brain Inj 2009; 23:39.
- Golfinos JG, Cooper PR. Skull fracture and post-traumatic cerebrospinal fluid fistula. In: Head Injury, 4th, Cooper PR, Golfinos JG (Eds), McGraw-Hill, New York 2000. p.155.
- Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013. MMWR Surveill Summ 2017; 66:1.
- Cooper PR, Ho V. Role of emergency skull x-ray films in the evaluation of the head-injured patient: a retrospective study. Neurosurgery 1983; 13:136.
- Jiang JY, Feng H, Fu Z, et al. Violent head trauma in China: report of 2254 cases. Surg Neurol 2007; 68 Suppl 2:S2.
- Poon WS, Rehman SU, Poon CY, Li AK. Traumatic extradural hematoma of delayed onset is not a rarity. Neurosurgery 1992; 30:681.
- Fabbri A, Servadei F, Marchesini G, et al. Early predictors of unfavourable outcome in subjects with moderate head injury in the emergency department. J Neurol Neurosurg Psychiatry 2008; 79:567.
- Carpenter MB. Gross anatomy of the brain. In: Core Text of Neuroanatomy, 4th, Williams & Wilkins, Baltimore 1991. p.23.
- Rockswold GL. Head Injury. In: Emergency Medicine: A Comprehensive Study Guide, 4th, Tintinalli JE (Ed), McGraw-Hill, New York 1996.
- GURDJIAN ES, WEBSTER JE, LISSNER HR. Studies on skull fracture with particular reference to engineering factors. Am J Surg 1949; 78:736.
- Ahmed KA, Alison D, Whatley WS, Chandra RK. The role of angiography in managing patients with temporal bone fractures: a retrospective study of 64 cases. Ear Nose Throat J 2009; 88:922.
- Ringer AJ, Matern E, Parikh S, Levine NB. Screening for blunt cerebrovascular injury: selection criteria for use of angiography. J Neurosurg 2010; 112:1146.
- Mulligan RP, Mahabir RC. The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg 2010; 126:1647.
- Braakman R. Survey and follow-up of 225 consecutive patients with a depressed skull fracture. J Neurol Neurosurg Psychiatry 1971; 34:106.
- Braakman R. Depressed skull fracture: data, treatment, and follow-up in 225 consecutive cases. J Neurol Neurosurg Psychiatry 1972; 35:395.
- Harris JH Jr. High yield criteria and skull radiography. JACEP 1979; 8:438.
- Jennett B, Miller JD. Infection after depressed fracture of skull. Implications for management of nonmissile injuries. J Neurosurg 1972; 36:333.
- Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of depressed cranial fractures. Neurosurgery 2006; 58:S56.
- Kaptigau WM, Ke L, Rosenfeld JV. Open depressed and penetrating skull fractures in Port Moresby General Hospital from 2003 to 2005. P N G Med J 2007; 50:58.
- Heary RF, Hunt CD, Krieger AJ, et al. Nonsurgical treatment of compound depressed skull fractures. J Trauma 1993; 35:441.
- Chesnut RM. Care of central nervous system injuries. Surg Clin North Am 2007; 87:119.
- Hasso AN, Ledington JA. Traumatic injuries of the temporal bone. Otolaryngol Clin North Am 1988; 21:295.
- Dahiya R, Keller JD, Litofsky NS, et al. Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations. J Trauma 1999; 47:1079.
- Nosan DK, Benecke JE Jr, Murr AH. Current perspective on temporal bone trauma. Otolaryngol Head Neck Surg 1997; 117:67.
- Yilmazlar S, Arslan E, Kocaeli H, et al. Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases. Neurosurg Rev 2006; 29:64.
- Tubbs RS, Shoja MM, Loukas M, et al. William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture. J Neurosurg 2010; 112:186.
- Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005; 294:1511.
- Pretto Flores L, De Almeida CS, Casulari LA. Positive predictive values of selected clinical signs associated with skull base fractures. J Neurosurg Sci 2000; 44:77.
- Savastio G, Golfieri R, Pastore Trossello M, Venturoli L. [Cranial trauma: the predictability of the presentation symptoms as a screening for radiologic study]. Radiol Med 1991; 82:769.
- Pulec JL, Deguine C. Temporal bone fracture with tympanic membrane perforation and hemorrhage. Ear Nose Throat J 2003; 82:344.
- Liang W, Xiaofeng Y, Weiguo L, et al. Traumatic carotid cavernous fistula accompanying basilar skull fracture: a study on the incidence of traumatic carotid cavernous fistula in the patients with basilar skull fracture and the prognostic analysis about traumatic carotid cavernous fistula. J Trauma 2007; 63:1014.
- York G, Barboriak D, Petrella J, et al. Association of internal carotid artery injury with carotid canal fractures in patients with head trauma. AJR Am J Roentgenol 2005; 184:1672.
- Resnick DK, Subach BR, Marion DW. The significance of carotid canal involvement in basilar cranial fracture. Neurosurgery 1997; 40:1177.
- Anglin D, Hutson HR, Luftman J, et al. Intracranial hemorrhage associated with tangential gunshot wounds to the head. Acad Emerg Med 1998; 5:672.
- Al-Haddad SA, Kirollos R. A 5-year study of the outcome of surgically treated depressed skull fractures. Ann R Coll Surg Engl 2002; 84:196.
- Ali B, Ghosh A. Antibiotics in compound depressed skull fractures. Emerg Med J 2002; 19:552.
- Qureshi NH, Harsh GR. Skull fractures. eMEDICINE, 2001. http://emedicine.medscape.com/article/248108-overview (Accessed on June 24, 2009).
- Michel O, Bamborschke S, Nekic M, Bachmann G. Beta-trace protein (prostaglandin D synthase)--a stable and reliable protein in perilymph. Ger Med Sci 2005; 3:Doc04.
- Santos SF, Rodrigues F, Dias A, et al. [Post-traumatic meningitis in children: eleven years' analysis]. Acta Med Port 2011; 24:391.
- Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2015; :CD004884.
- Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997; 18:188.
- Adegbite AB, Khan MI, Tan L. Predicting recovery of facial nerve function following injury from a basilar skull fracture. J Neurosurg 1991; 75:759.
- Maiman DJ, Cusick JF, Anderson AJ, Larson SJ. Nonoperative management of traumatic facial nerve palsy. J Trauma 1985; 25:644.
- Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J Trauma 2003; 54:492.
- Mina AA, Knipfer JF, Park DY, et al. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma 2002; 53:668.
- Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma 2006; 60:553.
- Karni A, Holtzman R, Bass T, et al. Traumatic head injury in the anticoagulated elderly patient: a lethal combination. Am Surg 2001; 67:1098.
- Franko J, Kish KJ, O'Connell BG, et al. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J Trauma 2006; 61:107.
- Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 2015; 48:137.
- Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 2012; 59:451.
- Cohn B, Keim SM, Sanders AB. Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med 2014; 46:410.
- ANATOMY AND MECHANISM OF INJURY
- PREHOSPITAL MANAGEMENT
- INITIAL EVALUATION
- DIAGNOSTIC IMAGING
- DEFINITION AND PRESENTATION OF SKULL FRACTURE TYPES
- Linear skull fracture
- Depressed skull fracture
- Basilar skull fracture
- Penetrating skull fracture
- MANAGEMENT OF SPECIFIC INJURIES
- Linear fractures
- Depressed fractures
- Basilar fractures
- Anticoagulated patients
- Penetrating injuries
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS