Skull fractures (also known as Basilar skull fracture, Depressed skull fracture, Linear skull fracture) may occur with head injuries. The skull provides good protection for the brain. However, a severe impact or blow can cause the skull to break. It may be accompanied by concussion or other injury to the brain.
The brain can be affected directly by damage to the nervous system tissue and bleeding. The brain can also be affected indirectly by blood clots that form under the skull and compress the underlying brain tissue (subdural or epidural hematoma).
Simple fracture
A simple fracture is a break in the bone without damage to the skin.
Linear fracture
A linear skull fracture is a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone.
Depressed fracture
A depressed skull fracture is a break in a cranial bone (or 'crushed' portion of skull) with depression of the bone in toward the brain.
Compound fracture
A compound fracture involves a break in, or loss of, skin and splintering of the bone.
Main causes of skull fractures
• Head trauma
• Falls, automobile accidents, physical assault, and sports
Some of the main symptoms of skull fractures include:
• Bleeding from wound, ears, nose, or around eyes
• Bruising behind the ears or under the eyes
• Changes in pupils (sizes unequal, not reactive to light)
• Confusion
• Convulsions
• Difficulties with balance
• Drainage of clear or bloody fluid from ears or nose
• Drowsiness
• Headache
• Loss of consciousness
• Nausea
• Restlessness, irritability
• Slurred speech
• Stiff neck
• Swelling
• Visual disturbances
• Vomiting
In some cases, the only symptom may be a bump on the head. A bump or bruise may take up to 24 hours to develop.
First Aid in case of skull fracture
Check the ‘ABC’ - airways, breathing, and circulation. If necessary, begin rescue breathing and CPR.
Avoid moving the person (unless absolutely necessary) until medical help arrives. Call immediately for medical assistance. If the person must be moved, take care to stabilize the head and neck. Place your hands on both sides of the head and under the shoulders. Do not allow the head to bend forward or backward, or to twist or turn.
Carefully check the site of injury, but do not probe in or around the site with a foreign object. It can be hard to know if the skull is fractured or depressed (dented in) at the site of injury.
If there is bleeding, apply firm pressure with a clean cloth over a broad area to control blood loss.
If blood soaks through, do not remove the original cloth. Instead, apply more cloths on top, and continue to apply pressure. If the person is vomiting, stabilize the head and neck, and carefully turn the victim to the side to prevent choking on vomit.
If the person is conscious and experiencing any of the previously listed symptoms, transport to the nearest emergency medical facility (even if the patient does not think medical help is needed).
Medical therapy for skull fracture
Adults with simple linear fractures who are neurologically intact do not require any intervention and may even be discharged home safely and asked to return if symptomatic. Infants with simple linear fractures should be admitted for overnight observation regardless of neurological status. Neurologically intact patients with linear basilar fractures also are treated conservatively, without antibiotics. Temporal bone fractures are managed conservatively, at least initially, because tympanic membrane rupture usually heals on its own.
Simple depressed fractures in neurologically intact infants are treated expectantly. These depressed fractures heal well and smooth out with time, without elevation. Seizure medications are recommended if the chance of developing seizures is higher than 20%. Open fractures, if contaminated, may require antibiotics in addition to tetanus toxoid.
Types I and II occipital condylar fractures are treated conservatively with neck stabilization, which is achieved with a hard collar or halo traction.
Surgical Therapy
The role of surgery is limited in the management of skull fractures. Infants and children with open depressed fractures require surgical intervention. Most surgeons prefer to elevate depressed skull fractures if the depressed segment is more than 5 mm below the inner table of adjacent bone. Indications for immediate elevation are gross contamination, dural tear with pneumocephalus, and an underlying hematoma.
At times, craniectomy is performed if the underlying brain is damaged and swollen. In these instances, cranioplasty is required at a later date. Another indication for early surgical intervention is an unstable occipital condylar fracture (type III) that requires atlantoaxial arthrodesis. This can be achieved with inside-outside fixation.
Follow-up
Adults with simple linear fractures of the vault, without any loss of consciousness at the time of initial presentation and with no other complications, do not require long-term follow-up. On the other hand, infants with similar fractures with dural tears need to be monitored more closely because of the possibility of the skull fracture expanding.
Patients with contaminated open depressed skull fractures treated surgically should be monitored with repeat CT scans a few times over the next 2-3 months to check for abscess formation. Follow-up also is dictated by the complications associated with skull fractures, for example, seizures, infections, and removal of bone pieces at the time of initial debridement.
Complications
Failure to recognize skull fracture has more consequences than the complications resulting from treatment. The chance of a concomitant cervical spine injury is 15%, and this should be kept in mind when assessing a patient with skull fracture.
Linear skull fracture
In infants and children, a simple linear fracture, if associated with a dural tear, can lead to subepicranial hygroma or a growing skull fracture (leptomeningeal cyst). This may take up to 6 months to develop, resulting from the brain pulsating against a dural defect that is larger than the bone defect. Repair of such a defect is performed using a split-thickness bone graft. Growing skull fracture has also been reported in literature following a stab wound to a gravid abdomen in the last trimester.
Basilar skull fracture
The risk of infection is not high, even without routine antibiotics, especially with CSF rhinorrhea. Facial palsy and ossicular chain disruption associated with basilar fractures are discussed in the Clinical section. However, notably, facial palsy that starts with a 2- to 3-day delay is secondary to neurapraxia of the VII cranial nerve and is responsive to steroids, with a good prognosis. A complete and sudden onset of facial palsy at the time of fracture usually is secondary to nerve transection, with a poor prognosis.
Depressed skull fracture
In addition to the risk of infection in contaminated depressed skull fractures, a risk of developing seizures also exists. The overall risk of seizures is low but is higher if the patient loses consciousness for longer than 2 hours, if an associated dural tear is present, and if the seizures start in the first week of injury.
Outcome and Prognosis
Although skull fractures carry a significant potential risk of cranial nerve and vascular injuries and direct brain injury, most skull fractures are linear vault fractures in children and are not associated with epidural hematoma. Most skull fractures, including depressed skull fractures, do not require surgery. Hence, all of the potential complications listed are associated with a graver prognosis if the primary fracture is missed during the diagnostic workup.
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