Skull Fracture Workup

Updated: Sep 27, 2018
  • Author: Nazer H Qureshi, MD; Chief Editor: Brian H Kopell, MD  more...
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Workup

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.

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Imaging Studies

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%. [28]

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. [29]

CT scan is the criterion standard modality for aiding in the diagnosis of skull fractures. [4, 5] 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. [7]

CT scan for skull fractures was found to have a  sensitivity of 85.4% and a specificity of 100% in one study. [30]  In another study, of children with skull fractures suspected of abusive head trauma, CT with 3-dimensional reconstruction was found to be 97% sensitive and 94% specific. [6]

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

 

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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.

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