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Skull Fracture

By James E. Wilberger, MD, Professor of Neurosurgery;Jannetta Endowed Chair, Department of Neurosurgery;DIO, Chairman Graduate Medical Education Committee;Vice-President, Graduate Medical Education, Drexel University College of Medicine;Allegheny General Hospital;Allegheny Health Network Medical Education Consortium;Allegheny Health Network ; Gordon Mao, MD, PGY 5 Neorosurgery Resident, Allegheny Health Network

A skull fracture is a break in a bone surrounding the brain.

  • Skull fractures can occur with or without brain damage.

  • Symptoms may include pain, symptoms of brain damage, and, in certain fractures, fluid leaking from the nose or ears or bruises behind the ears or around the eyes.

  • Computed tomography is used to diagnose skull fractures.

  • Many skull fractures require no treatment.

Skull fractures can result from injuries that break the skin (called open injuries) or do not break the skin (called closed injuries).

In people with a skull fracture, brain damage may be more severe than in people with a head injury but no fracture. How serious a skull fracture is depends partly on the type and location of the fracture. Often, if skull bones break but remain in place, the brain is not damaged.

Some skull fractures injure arteries and veins, which then bleed into the spaces around brain tissue. Blood may accumulate between the brain and the skull, causing an intracranial hematoma.

Some fractures, especially those at the back and bottom (base) of the skull, tear the meninges, the layers of tissue that cover the brain. Fractures at the base of skull, which is very thick, indicate that the injury was high-impact and brain damage is more likely.

If a fracture breaks the skin, bacteria may enter the skull through the fracture, causing infection and severe brain damage.

Sometimes, pieces of the fractured skull bone press inward and damage the brain. These types of fractures are called depressed fractures. Depressed skull fractures may expose the brain to the environment and foreign material, leading to infection or the formation of abscesses (collections of pus) within the brain.

Skull fractures in infants

In infants who have a skull fracture, the meninges surrounding the brain occasionally protrude through and become trapped by the fracture, forming a fluid-filled sac called a growing fracture or leptomeningeal cyst. The sac develops over 3 to 6 weeks and may be the first evidence that the skull was fractured.

Symptoms

Certain symptoms suggest a fracture at the base of the skull:

  • Cerebrospinal fluid—the clear fluid that flows over the surface of the brain between the meninges—may leak from the nose (rhinorrhea) or ears (otorrhea).

  • Blood may collect behind the eardrum, or if the eardrum is ruptured, blood may drain from the ear.

  • Bruises may develop behind the ear (Battle sign) or around the eyes (raccoon eyes).

Blood may collect in the sinuses, which may also be fractured.

If the fracture has damaged the brain, people may have symptoms such as the following:

  • Persistent or increasing sleepiness and confusion

  • Seizures

  • Repeated vomiting

  • Severe headache

  • Inability to feel or move an arm or leg

  • Difficulty recognizing people or the surroundings

  • Loss of balance

  • Problems speaking or seeing

  • Lack of coordination

Diagnosis

  • Computed tomography

Doctors suspect a skull fracture based on circumstances, symptoms, and results of a physical examination in people who have had a head injury.

To confirm a skull fracture, doctors use computed tomography (CT). CT is better than magnetic resonance imaging (MRI) for diagnosing skull fractures. However, CT or MRI is usually done to check for brain damage.

X-rays of the skull are rarely helpful in people who had a head injury.

Did You Know...

  • X-rays of the skull are rarely helpful in people who had a head injury.

Treatment

  • For most fractures, observation in the hospital

  • Sometimes surgery to remove foreign materials and/or put skull fragments back in place

Most people with skull fractures without brain injury are admitted to the hospital and observed. People who develop seizures require anticonvulsants. Other than fractures of the base of the skull and depressed skull fractures, most skull fractures require no specific treatment.

Fractures at the base of the skull

People with a fracture of the base of the skull are admitted to the hospital. Bed rest and head elevation are needed until cerebrospinal fluid stops leaking. People should avoid blowing their nose because often a sinus near the nose is also fractured. If so, blowing the nose can cause air from the nose to spread to other parts of the face or head.

Most tears in the meninges seal up on their own within 48 hours or at least within a week after the injury.

If cerebrospinal fluid continues to leak, doctors can sometimes drain the fluid by inserting a small needle in the lower back. If fluid continues to leak, the leak is closed surgically.

Depressed skull fractures

Depressed skull fractures increase the risk of infections because they may expose the brain to the outside. So doctors aim to prevent infection and the formation of abscesses by removing foreign materials and dead tissue and repairing as much of the damage as possible. Doctors lift skull fragments back into position and stitch the wound closed.

Skull fractures in children

A child with a skull fracture is admitted to the hospital if

  • Symptoms suggest possible brain injury.

  • The child was unconscious, even briefly.

  • Symptoms or CT findings suggest a fracture at the base of the skull.

  • The fracture occurs in an infant.

  • Child abuse is suspected.

Treatment of leptomeningeal cysts may involve observation only since these fluid-filled sacs sometimes heal themselves. In children who develop or become at risk of developing problems such as pressure on the brain or infection, doctors insert a catheter into the cyst and surgically drain it. Then they repair the meninges that formed the cyst.

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