Hello Surgeon

X

How can we help you today?

Post

Skull Fracture Overview & Treatment

Skull fractures affect the neurocranium, which envelops the brain, and are not classified as maxillofacial skeletal fractures, even though skull fractures may communicate with maxillofacial fractures in severely injured patients.

Thus, skull fractures are normally treated by neurosurgeons. Maxillofacial or mandible fractures go to maxillofacial surgeons. A basic overview of skull fractures and their typical signs important for orthopedic surgeons is discussed in the following paragraphs.

Related Anatomy

The brain is an exceptionally fragile organ surrounded by CSF, enclosed in a meningeal covering and protected inside the skull. CSF plays a key role in coup and contrecoup injuries to the brain. A blow to a stationary but moveable head causes acceleration, and the brain floating in CSF lags behind, sustaining an injury directly underneath the point of impact (coup injury). When a moving head hits the floor, sudden deceleration results in an injury to the brain on the opposite side (contrecoup injury).

The skull has several condensed areas, such as the mastoid processes, the glabella, the external occipital protuberance and the external angular process. The skull is joined by three arches on either side.

The skull vault is composed of cancellous bone sandwiched between two tablets, the lamina externa (1.5 mm) and the lamina interna (0.5 mm).

See Also: Cranial Nerves

Skull Fracture Patterns

Fractures of the skull may also follow typical patterns at certain anatomic sites. The thin squamous temporal and parietal bones over the temples and the sphenoid sinus, the foramen magnum, the petrous temporal ridge, and the inner parts of the sphenoid wings at the skull base are often included in the fracture lines.

The middle cranial fossa is the weakest area, because of thin bones and several foramina. Other sites prone to fracture include the cribriform plate and the roof of orbits in the anterior cranial fossa and the areas between the mastoid and dural sinuses in the posterior cranial fossa.

Skull Fracture Classification

Skull fractures can be roughly classified as linear or depressed.

Simple linear fracture is by far the most common type of fracture, especially in children younger than 5 years. Temporal bone fractures represent 15–48% of all skull fractures. Basilar skull fractures represent 19–21% of all skull fractures. Depressed fractures are frontoparietal (75%), temporal (10%), occipital (5%) and other (10%). Most of the depressed fractures are open fractures.

Linear skull fractures

Low-energy or blunt trauma over a broad plane of the skull may result in linear fractures. These fractures are often without consequence. Patients with uncritical linear skull fractures are frequently clinically asymptomatic. Often only swelling occurs at the site of impact, and the skin may or may not be ruptured. But linear fractures could possibly cause significant problems when they run through vascular foramina, the venous sinus grooves or a suture. Under these circumstances severe epidural haematoma, venous sinus thrombosis and occlusion or sutural diastasis may develop and a neurosurgeon should be consulted.

Basilar fractures are at the base of the skull and are mostly linear fractures. They are regularly associated with a dural tear. The majority of linear skull base fractures run into the temporal bone. It is important to subdivide temporal basilar fractures into petrous and non-petrous fractures; the latter include fractures that involve mastoid air cells. These fractures do not present with cranial nerve deficits.

Patients with petrous temporal bone fractures may present with CSF otorrhoea and bruising over the mastoids. Anterior cranial fossa fractures are often associated with midfacial fractures and could result in CSF rhinorrhoea. Loss of consciousness and Glasgow Coma Scale score may vary depending on an associated intracranial pathological condition. Longitudinal temporal bone fractures can result in conductive deafness of greater than 30 dB due to ossicular chain disruption.

Deafness lasts longer than 6 weeks. Temporary deafness that resolves in less than 3 weeks is due to haemotympanum and mucosal oedema in the middle ear fossa. Facial palsy, nystagmus and facial numbness are secondary to involvement of the seventh, sixth and fifth cranial nerves, respectively. Transverse temporal bone fractures involve the eighth cranial nerve and the labyrinth, resulting in nystagmus, ataxia and permanent neural hearing loss.

Linear skull fractures

Depressed skull fractures

High-energy trauma to a small surface area of the skull often causes depressed skull fractures (e.g. blow with a hammer). Comminution of fragments starts from the point of maximum impact and spreads centrifugally. Bone fragments should be depressed greater than the adjacent inner table of the skull to be of clinical significance, requiring operation and elevation. Neurological signs such as loss of consciousness and reduced Glasgow Coma Scale score are more frequent in depressed fractures and may vary depending on other associated intracranial injuries such as epidural haematoma, dural tears and seizures.

Depressed skull fractures

Open fractures may be identified by skin lacerations above the fracture and often lead to contamination. Fractures running through the orbit, the paranasal sinuses and middle ear structures can also produce an open fracture, when air enters the cranial cavity. In these situations trapped air is detectable between the fractured bones and the brain silhouette on CT scans. Consultation with a neurosurgeon is important.

If a skull fracture is suspected or cannot be ruled out radiographic examination must be performed. A posterior– anterior and lateral cranial view of the skull gives a first impression. A CT scan is the preferred option. In plain radiographs the distinction between fracture lines and sutures may be difficult for the inexperienced viewer.

Depressed skull fractures xray

Skull Fractures Treatment

The role of surgery is limited in the management of skull fractures. Adults with simple linear skull fractures and absence of neurological symptoms may not require any intervention at all. Surgery is often not necessary, but treatment decisions should be made according to a neurosurgeon’s advice.

Open fractures with severe contamination, dural tear, trapped intracranial air (pneumocephalus), intracranial hematoma or unstable occipital condylar spine fracture require immediate surgical treatment. Another indication for surgical treatment is a persistent CSF leak. An atlantoaxial arthrodesis can be attained with an inside–outside fixation. Craniectomy with resection of skull segments is performed if the underlying brain is damaged and swollen. In these instances, cranioplasty is required at a later date.

Craniectomy
Craniectomy

Infant Skull Fracture Treatment

Infant skull fractures with simple linear fractures need at least overnight observation regardless of neurological status.

Uncomplicated depressed fractures in neurologically intact infants often heal well and smooth out with time, without elevation or surgical intervention. Problematical open depressed fractures in infants and children must be forwarded to a neurosurgeon as surgical intervention is required. Many neurosurgeons favour elevation of depressed skull fractures if the displaced segment is more than 5 mm below the inner table of the adjacent fracture segments.

infant skull fracture
Infant skull fracture

References & More

  1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
  2. Qureshi N, Harsh G 4th. Skull fractures. http://www. emedicine.com/med/TOPIC2894.HTM
  3. Pait TG, Al-Mefty O, Boop FA, et al. Inside-outside technique for posterior occipitocervical spine instrumentation and stabilization: preliminary results. Journal of Neurosurgery 1999;90(1 Suppl.):1–7. Pubmed
Last Reviewed
January 14, 2024
Contributed by
OrthoFixar

Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice.

Angle Meter App for Android & iOS
  • Lifetime product updates
  • Install on one device
  • Lifetime product support
One-Click Purchase
Orthopedic FRCS VIVAs Quiz
  • Lifetime product updates
  • Install on one device
  • Lifetime product support
One-Click Purchase
Top 12 Best Free Orthopedic Apps
  • Lifetime product updates
  • Install on one device
  • Lifetime product support
One-Click Purchase
All-in-one Orthopedic App
  • Lifetime product updates
  • Install on one device
  • Lifetime product support
One-Click Purchase