Skull Fracture

Classification

Linear Skull Fracture

Results from low-energy blunt trauma over a wide area of skull. Through entire thickness. Of less significance if vasculature, venous sinus or suture are not involved. If involved, may cause epidural hematoma, venous sinus thrombosis and occlusion and sutural diastasis. Vault fractures may resemble sutures

Fractures
- > 3mm in width - Widest at center, narrow at ends - Darker on x-ray (entire thickness)

Sutures
- < 2mm in width - Same width throughout - Lighter on x-ray

- Usually temporoparietal area

- Usually in straight line - Angular turns

- Specific anatomic sites

- Not in straight line - Curvaceous

Presentation
Mostly asymptomatic if important structures are not involved. May have swelling at the site of impact.

Basilar Skull Fracture

Base of the skull (temporal, occipital, sphenoid or ethmoid bone) Associated with dural tear. Most commonly involves temporal bone. Temporal bone fracture : longitudinal, transverse or mixed. Occipital condylar fracture : results from high energy blunt trauma with axial compression, lateral bending or rotational injury to the alar ligament.

Presentation
Presentation depends on the bone fractured. Battles sign, ecchymosis of the mastoid process, indicating fracture of middle cranial fossa and possible underlying brain damage. Raccoons eyes, periorbital ecchymosis associated with frontal basal fracture. CSF rhinorrhea CSF otorhea Bleeding from nose or ears Cranial nerve palsy

Depressed Skull Fracture

High-energy blunt trauma to a small area. Comminution of fragments spread centrifugally. Mostly over frontoparietal region because the bone is thin and prone to attack. High risk of increased intracranial pressure. A free piece of bone should be depressed greater than adjacent inner table of the skull to be of significance and requiring elevation. May be open or closed. Open fractures have a skin laceration or fracture results in communication between the external environment and the cranial cavity.

Presentation
Epidural hematoma Dural tears Seizures Loss of consciousness

Investigation
CT scan is the standard modality for aiding diagnosis. X-ray is of no benefit if CT scan is obtained. MRI is useful only for ligamentous and vascular injuries. When there is bleeding and suspected CSF leak, when dabbed on a tissue paper, shows a clear ring of wet tissue beyond the blood stain, called a halo sign. Neurological examination, baseline lab analysis and tetanus toxoid (in case of open fractures)

Management
Adults with simple linear fractures who are neurologically intact do not require any intervention and may be discharged and asked to return if symptomatic. Neurologically intact patients with linear basilar fractures are treated conservatively without antibiotics. Surgery usually indicated to elevate depressed fragments more than 5mm below the inner table of adjacent bone.