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skull fracture (cranial fracture)
Also see head trauma.
Classification:
1) simple fracture: a break in bone without damage to skin
2) linear skull fracture: a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone
3) depressed skull fracture: break in a cranial bone (or 'crushed' portion of skull) with depression of the bone in toward the brain.
4) compound fracture: a break in, or loss of, skin & splintering of the bone
5) basilar skull fractures involve the base of the skull; includes most skull fractures
6) Rene Le Fort, a French surgeon, identified lines of weakness in the facial bones where fractures are most likely to occur
a) type 1 runs across the maxilla, or upper jaw
b) type 2 is pyramidal in shape, breaking the cheekbone below the orbit (eye socket) & running across the bridge of the nose
c) type 3 separates the frontal bone behind the forehead from the zygoma (cheekbone) as well as breaking the nasal bridge (craniofacial separation)
Etiology:
- head injury, including falls, automobile accidents, physical assault, & sports injuries
Physiology:
- 10 times more force is required to fracture a cadaveric skull with overlaying scalp than the one without
- diploe does not form where the skull is covered with muscles leaving the vault thin and prone to fracture
Pathology:
- the skull is prone to fracture at certain sites including
a) thin squamous temporal bone & parietal bones over the temples
b) sphenoid sinus
c) foramen magnum
d) petrous temporal ridge
e) inner parts of the sphenoid wings at the skull base
- the middle cranial fossa is the weakest, with thin bones & multiple foramina
- other site prone to fracture include
a) cribriform plate
b) roof of orbits in the anterior cranial fossa
c) areas between the mastoid & dural sinuses in the posterior cranial fossa
Clinical manifestations:
- most patients with linear skull fractures are asymptomatic
- signs suggestive of skull fracture include:
a) bleeding from wound, ears, nose, or around eyes
b) ecchymoses behind the ears (Battle sign) or under the eyes
c) drainage of clear or bloody fluid from ears or nose
- ~25% of patients with depressed skull fracture do not report loss of consciousness, ~25% lose consciousness for < 1 hour
- presentation may vary depending on other associated intracranial injuries
- see head trauma
Radiology:
- computed tomography is the imaging modality of choice [1]
Management:
- adults with simple linear fractures without neurological deficits do not require any intervention & may be discharged home to return if symptomatic
- children with uncomplicated skull fractures should be discharged home [5]
- role of surgery is limited
a) infants & children with open depressed fractures require surgical intervention
b) consult neurosurgery
Related
skull (cranium)
Specific
Leforte fracture
maxillary fracture
nasal fracture
orbital fracture (blowout fracture)
zygomatic fracture
General
bone fracture
head injury
References
- Medical Knowledge Self Assessment Program (MKSAP) 15,
American College of Physicians, Philadelphia 2009
- Medline Plus
http://www.nlm.nih.gov/medlineplus/ency/article/000060.htm
- Qureshi H and Harsh G
eMedicine: Skull Fracture
http://emedicine.medscape.com/article/248108-overview
- Encyclopedia of Surgery: Craniofacial reconstruction
http://www.surgeryencyclopedia.com/Ce-Fi/Craniofacial-Reconstruction.html
- Lyons TW, Stack AM, Monuteaux MC et al.
A QI initiative to reduce hospitalization for children with
isolated skull fractures.
Pediatrics 2016 May 11
PMID: 27244848
http://pediatrics.aappublications.org/content/early/2016/05/09/peds.2015-3370