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Skull Fracture Workup

  • Author: Nazer H Qureshi, MD; Chief Editor: Brian H Kopell, MD  more...
Updated: May 26, 2016

Laboratory Studies

In addition to a complete neurological examination, baseline laboratory analyses, and tetanus toxoid (where appropriate, as in open skull fractures), the diagnostic workup for fractures is radiological.


Imaging Studies

In 1987, the skull x-ray referral criteria panel decided that skull films are suboptimal in revealing basilar skull fractures. Hence, other than a fracture at the vertex that might be missed by CT scan and picked up by a plain film, skull x-ray is of no benefit when a CT scan is obtained. In one study, skull x-ray missed 19.1% of fractures, whereas CT scan missed 11.9%.[19]

In a retrospective review of 21 infants with possible skull fracture after birth trauma, skull films at the birth hospital were found to be unreliable for fracture in 23% of cases. Seven of nine infants with accidental falls had fracture on computed tomography scan. Only three infants required neurosurgical intervention, all after severe birth trauma associated with instrumentation.[20]

CT scan is the criterion standard modality for aiding in the diagnosis of skull fractures.[21, 22] Thinly sliced bone windows of up to 1-1.5 mm thick, with sagittal reconstruction, are useful in assessing injuries. Helical CT scan is helpful in occipital condylar fractures, but 3-dimensional reconstruction usually is not necessary.[23]

CT scan for skull fractures was found to have a  sensitivity of 85.4 % and a specificity of 100% in one study.[24]

MRI or magnetic resonance angiography is of ancillary value for suspected ligamentous and vascular injuries. Bony injuries are far better visualized using CT scan.



Other Tests

Bleeding from the ear or nose in cases of suspected CSF leak, when dabbed on a tissue paper, shows a clear ring of wet tissue beyond the blood stain, called a "halo" or "ring" sign. A CSF leak can also be revealed by analyzing the glucose level and by measuring tau-transferrin.

Contributor Information and Disclosures

Nazer H Qureshi, MD Neurosurgeon, Princeton Brain and Spine

Nazer H Qureshi, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, World Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons

Disclosure: Received none from NMT Inc for consulting.


Griffith Harsh IV, MD Professor, Director of Neurosurgical Oncology, Department of Neurosurgery, Stanford Medical Center, Stanford University School of Medicine

Griffith Harsh IV, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, California Medical Association, Neurosurgical Society of America, North American Skull Base Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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Classification of skull fractures
Transverse temporal bone fracture (courtesy of Adam Flanders, MD, Thomas Jefferson University, Philadelphia, Pennsylvania)
Longitudinal temporal bone fracture (courtesy of Adam Flanders, MD, Thomas Jefferson University, Philadelphia, Pennsylvania)
Depressed skull fracture (courtesy of Adam Flanders, MD, Thomas Jefferson University, Philadelphia, Pennsylvania)
Table 1. Differences Between Skull Fractures and Sutures
Fractures Sutures
  • Greater than 3 mm in width
  • Widest at the center and narrow at the ends
  • Runs through both the outer and the inner lamina of bone, hence appears darker
  • Usually over temporoparietal area
  • Usually runs in a straight line
  • Angular turns
  • Less than 2 mm in width
  • Same width throughout
  • Lighter on x-rays compared with fracture lines
  • At specific anatomic sites
  • Does not run in a straight line
  • Curvaceous
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