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) as well as from those that do not break the skin (called closed injuries). (See also Overview of Head Injuries.)
In some 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 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 of Skull Fracture
Skull fractures are usually associated with focal headaches, tenderness, and overlying scalp contusions or lacerations. Open skull fractures occur when the scalp has a deep cut (laceration) that exposes the bone to the outside. Open skull fractures usually require urgent surgery. More severe skull fractures can be depressed or comminuted. In a depressed skull fracture, the fractured bone edge on one side is pushed inward , often causing underlying brain injury. In a comminuted skull fracture, the fracture is severe enough to cause the bone to fragment into numerous smaller pieces. High-energy impacts or high-speed car crashes can lead to skull base fractures, in which the fracture involves bones at the base of the skull. Skull base fractures are often associated with traumatic brain injury, spinal fluid leakage, and even injury to major arteries, such as the carotid artery),or veins supplying the brain.
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).
Air can enter the intracranial compartment surrounding the brain through basal skull fractures that communicate with the sinonasal cavities (pneumocephalus).
This photo shows bruises behind the ear called the Battle sign. The Battle sign may mean a person has a fracture at the base of their skull.
© Springer Science+Business Media
This photo shows bruises around the eyes called raccoon eyes. Raccoon eyes may mean a person has a fracture at the base of their skull.
© Springer Science+Business Media
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
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 of Skull Fracture
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 have had a head injury.
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Treatment of Skull Fracture
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 antiseizure medications. Other than fractures of the base of the skull and depressed skull fractures, most skull fractures require no specific treatment.
Open skull fractures
Open skull fractures increase the risk of infections because they may expose the brain to the outside. 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.
Depressed skull fractures
Depressed skull fractures may be associated with underlying brain injury due to the direct pressure of the broken bone fragment, seizures, cerebrospinal fluid leak (if the fracture is also open), or long-term cosmetic defects. Minor depressed fractures, in which the bone is minimally indented, may not require surgery. More severe fractures, in which the bone impinges on the brain or clearly visible fractures that involve the upper face or forehead require surgical consultation and possible intervention.
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.
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 because these fluid-filled sacs sometimes heal themselves. Sometimes doctors insert a catheter into the cyst and surgically drain it if children are thought to be at risk of developing problems such as pressure on the brain or infection. Then they repair the meninges that formed the cyst.
