Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

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.

Next

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.

 

Previous
Next

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.

Previous
 
 
Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

References
  1. Cantu RC. Head and spine injuries in youth sports. Clin Sports Med. 1995 Jul. 14(3):517-32. [Medline].

  2. Atta HM. Edwin Smith Surgical Papyrus: the oldest known surgical treatise. Am Surg. 1999 Dec. 65(12):1190-2. [Medline].

  3. Prioreschi P. Skull trauma in Egyptian and Hippocratic medicine. Gesnerus. 1993. 50 ( Pt 3-4):167-78. [Medline].

  4. Aciduman A, Arda B, Ozaktürk FG, Telatar UF. What does Al-Qanun Fi Al-Tibb (the Canon of Medicine) say on head injuries?. Neurosurg Rev. 2009 Jul. 32(3):255-63; discussion 263. [Medline].

  5. Turgut M. Serefeddin Sabuncuoglu (1385-1468) on pediatric skull fractures. Historical vignette. Pediatr Neurosurg. 2008. 44(4):264-8. [Medline].

  6. Bell C. Surgical observation. Middlesex Hosp Jour. 1817. 4:469.

  7. Ahlgren P, Mygind T, Wilhjelm B. [An unusual fracture of the base of the skull.]. Fortschr Geb Rontgenstr Nuklearmed. 1962 Sep. 97:388-91. [Medline].

  8. Peeters F, Verbeeten B. Evaluation of occipital condyle fracture and atlantic fracture, two uncommon complications of cranio-vertebral trauma. Rofo. 1983 May. 138(5):631-3. [Medline].

  9. Wennmo C, Spandow O. Fractures of the temporal bone--chain incongruencies. Am J Otolaryngol. 1993 Jan-Feb. 14(1):38-42. [Medline].

  10. Ishman SL, Friedland DR. Temporal bone fractures: traditional classification and clinical relevance. Laryngoscope. 2004 Oct. 114(10):1734-41. [Medline].

  11. Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine (Phila Pa 1976). 1988 Jul. 13(7):731-6. [Medline].

  12. Tuli S, Tator CH, Fehlings MG, Mackay M. Occipital condyle fractures. Neurosurgery. 1997 Aug. 41(2):368-76; discussion 376-7. [Medline].

  13. Menku A, Koc RK, Tucer B, Durak AC, Akdemir H. Clivus fractures: clinical presentations and courses. Neurosurg Rev. 2004 Jul. 27(3):194-8. [Medline].

  14. Ingram MD Jr, Hamilton WM. Cephalohematoma in the newborn. Radiology. 1950 Oct. 55(4):502-7. [Medline].

  15. Legros B, Fournier P, Chiaroni P, Ritz O, Fusciardi J. Basal fracture of the skull and lower (IX, X, XI, XII) cranial nerves palsy: four case reports including two fractures of the occipital condyle--a literature review. J Trauma. 2000 Feb. 48(2):342-8. [Medline].

  16. Collet FJ. Sur un nouveau syndrome paralatique pharyngologe par blessure de guerre (hemiplegie glosso-laryngo-scapulo-pharynge). Lyon Med. 1917. 124:121-9.

  17. Sicard JA. Syndrome de carrefour condylo-dechire posterior (type pur paralysie des quatre derniers nerf craniens. Mars Med. 1917. 53:385-97.

  18. Rebattu J, Bertoin R. Syndromes des quatre derniers nerfs craniens (Syndrome de Collet) par fracture de l'occipital. Ann des Maladies de l'Orielle, du nez et du pharaynx. 1925. 44:1013-22.

  19. Chawla H, Malhotra R, Yadav RK, Griwan MS, Paliwal PK, Aggarwal AD. Diagnostic Utility of Conventional Radiography in Head Injury. J Clin Diagn Res. 2015 Jun. 9 (6):TC13-5. [Medline].

  20. Merhar SL, Kline-Fath BM, Nathan AT, Melton KR, Bierbrauer KS. Identification and management of neonatal skull fractures. J Perinatol. 2016 Apr 7. [Medline].

  21. Idriz S, Patel JH, Ameli Renani S, Allan R, Vlahos I. CT of Normal Developmental and Variant Anatomy of the Pediatric Skull: Distinguishing Trauma from Normality. Radiographics. 2015 Jul 31. 140177. [Medline].

  22. Orman G, Wagner MW, Seeburg D, Zamora CA, Oshmyansky A, Tekes A, et al. Pediatric skull fracture diagnosis: should 3D CT reconstructions be added as routine imaging?. J Neurosurg Pediatr. 2015 Jul 17. 1-6. [Medline].

  23. Tseng WC, Shih HM, Su YC, Chen HW, Hsiao KY, Chen IC. The association between skull bone fractures and outcomes in patients with severe traumatic brain injury. J Trauma. 2011 Dec. 71(6):1611-4. [Medline].

  24. Chawla H, Yadav RK, Griwan MS, Malhotra R, Paliwal PK. Sensitivity and specificity of CT scan in revealing skull fracture in medico-legal head injury victims. Australas Med J. 2015. 8 (7):235-8. [Medline].

  25. Arrey EN, Kerr ML, Fletcher S, Cox CS Jr, Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted?. J Neurosurg Pediatr. 2015 Sep 4. 1-6. [Medline].

  26. Pait TG, Al-Mefty O, Boop FA, Arnautovic KI, Rahman S, Ceola W. Inside-outside technique for posterior occipitocervical spine instrumentation and stabilization: preliminary results. J Neurosurg. 1999 Jan. 90(1 Suppl):1-7. [Medline].

  27. Bonfield CM, Naran S, Adetayo OA, Pollack IF, Losee JE. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr. 2014 Aug. 14(2):205-11. [Medline].

  28. Metzinger SE, Guerra AB, Garcia RE. Frontal sinus fractures: management guidelines. Facial Plast Surg. 2005 Aug. 21(3):199-206. [Medline].

  29. Gallo P, Mazza C, Sala F. Intrauterine head stab wound injury resulting in a growing skull fracture: a case report and literature review. Childs Nerv Syst. 2009 Aug 7. [Medline].

  30. Singh I, Rohilla S, Siddiqui SA, Kumar P. Growing skull fractures: guidelines for early diagnosis and surgical management. Childs Nerv Syst. 2016 Mar 29. [Medline].

  31. Epstein JA, Epstein BS, Small M. Subepicranial hydroma. A complication of head injuries in infants and children. J Pediatr. 1961 Oct. 59:562-6. [Medline].

  32. Hassan SF, Cohn SM, Admire J, Nunez-Cantu O, Arar Y, Myers JG, et al. Natural history and clinical implications of nondepressed skull fracture in young children. J Trauma Acute Care Surg. 2014 Jul. 77(1):166-9. [Medline].

  33. Huang YC, Simmons C, Kaigler D, Rice KG, Mooney DJ. Bone regeneration in a rat cranial defect with delivery of PEI-condensed plasmid DNA encoding for bone morphogenetic protein-4 (BMP-4). Gene Ther. 2005 Mar. 12(5):418-26. [Medline].

  34. Shibuya TY, Wadhwa A, Nguyen KH, et al. Linking of bone morphogenetic protein-2 to resorbable fracture plates for enhancing bone healing. Laryngoscope. 2005 Dec. 115(12):2232-7. [Medline].

  35. [Guideline] Shetty VS, Reiss MN, Aulino JM, et al. ACR Appropriateness Criteria head trauma. National Guideline Clearinghouse. Available at http://www.guideline.gov/content.aspx?id=49914&search=acr+appropriateness+criteria%c2%ae+head+trauma. 2015; Accessed: May 26, 2016.

  36. [Guideline] Ryan ME, Palasis S, Saigal G, et al. ACR Appropriateness Criteria head trauma--child. National Guideline Clearinghouse. Available at http://www.guideline.gov/content.aspx?id=48288&search=acr+appropriateness+criteria%c2%ae+head+trauma. 2014; Accessed: May 26, 2016.

  37. Schaller B, Hosokawa S, Büttner M, Iizuka T, Thorén H. Occurrence, types and severity of associated injuries of paediatric patients with fractures of the frontal skull base. J Craniomaxillofac Surg. 2011 Nov 9. [Medline].

 
Previous
Next
 
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
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.