SKULL FRACTURE: TREATMENT AND MANAGEMENT

The brain is surrounded by cerebrospinal fluid (CSF), enclosed in meningeal covering, and
protected inside the skull. Furthermore, the fascia and muscles of the scalp provide additional
cushioning to the brain. Test results have shown that 10 times more force is required to fracture
a cadaveric skull with overlaying scalp than the one without.[1] Although these layers play a
protective role, meningeal attachments to the interior of the skull may limit the movement of the
brain, transmitting shearing forces on the brain.
A transverse temporal bone fracture is shown in the image below.

Transverse temporal bone fracture (courtesy of Adam Flanders,

MD, Thomas Jefferson University, Philadelphia, Pennsylvania)
CSF plays a major role in coup and countercoup 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 (countercoup injury).
Anatomy of fracture
The causative forces and fracture pattern, type, extent, and position are important in assessing
the sustained injury. The skull is thickened at the glabella, external occipital protuberance,
mastoid processes, and external angular process and is joined by 3 arches on either side. The
skull vault is composed of cancellous bone (diplo) sandwiched between 2 tablets, the lamina
externa (1.5 mm), and the lamina interna (0.5 mm). The diplo does not form where the skull is
covered with muscles, leaving the vault thin and prone to fracture.
The skull is prone to fracture at certain anatomic sites that include 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. The middle cranial
fossa is the weakest, with thin bones and multiple foramina. Other places 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.
History of the Procedure
Skull fracture is described in Edwin Smith's papyrus, the oldest known surgical paper.[2] The
papyrus describes a conservative and expectant approach to skull trauma, with better results
compared with a more aggressive and less favorable approach described in Hippocratic
medicine.[3]
An extensive discussion of skull fractures and their management is available in the eleventh
century manuscript, "Al-Qanun Fil-Tibb" by Ibn-Sina (Avicenna). This book was a predecessor
to the modern medicine literature.[4]

The 15th century management of pediatric skull fractures is illustrated by a Turkish physician of
the Ottoman Empire, Serefeddin Sabuncuolu (1385-1468) in his textbook "Cerrahiyyetu'l
Haniyye" (Imperial Surgery).[5]
Charles Bell first described occipital condylar fracture in 1817 based on an autopsy
finding.[6] The same fracture was described for the first time as a radiograph finding in 1962 and
by computed tomography (CT) in 1983.[7, 8]
Problem
Fractures of the skull can be classified as linear or depressed. Linear fractures are either vault
fractures or skull base fractures.[9] Vault fractures and depressed fractures can be either closed
or open (clean or dirty/contaminated).
Skull fractures are classified in the image below.

Classification of skull fractures

Linear skull fracture

Linear fracture results from low-energy blunt trauma over a wide surface area of the skull. It
runs through the entire thickness of the bone and, by itself, is of little significance except when it

runs through a vascular channel, venous sinus groove, or a suture. In these situations, it may
cause epidural hematoma, venous sinus thrombosis and occlusion, and sutural diastasis,
respectively. Differences between sutures and fractures are summarized in Table 1.
Table 1. Differences Between Skull Fractures and Sutures (Open Table in a new window)
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

Basilar skull fracture

In essence, a basilar fracture is a linear fracture at the base of the skull. It is usually associated
with a dural tear and is found at specific points on the skull base.
Temporal fracture
Temporal bone fracture is encountered in 75% of all skull base fractures. The 3 subtypes of
temporal fractures are longitudinal, transverse, and mixed.[10] A transverse temporal bone
fracture and a longitudinal temporal bone fracture are shown below.

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)
Longitudinal fracture occurs in the temporoparietal region and involves the squamous portion of
the temporal bone, the superior wall of the external auditory canal, and the tegmen tympani.
These fractures may run either anterior or posterior to the cochlea and labyrinthine capsule,

ending in the middle cranial fossa near the foramen spinosum or in the mastoid air cells,
respectively. Longitudinal fracture is the most common of the 3 subtypes (70-90%).
Transverse fractures begin at the foramen magnum and extend through the cochlea and
labyrinth, ending in the middle cranial fossa (5-30%).
Mixed fractures have elements of both longitudinal and transverse fractures.
Yet another classification system of temporal bone fractures has been proposed. This system
divides temporal bone fractures into petrous and nonpetrous fractures; the latter includes
fractures that involve mastoid air cells. These fractures do not present with cranial nerve
deficits.[11]
Occipital condylar fracture
Occipital condylar fracture results from a high-energy blunt trauma with axial compression,
lateral bending, or rotational injury to the alar ligament. These fractures are subdivided into 3
types based on the morphology and mechanism of injury.[12] An alternative classification divides
these fractures into displaced and stable, ie, with and without ligamentous injury.[13]
Type I fracture is secondary to axial compression resulting in comminution of the occipital
condyle. This is a stable injury.
Type II fracture results from a direct blow, and, despite being a more extensive basioccipital
fracture, type II fracture is classified as stable because of the preserved alar ligament and
tectorial membrane.
Type III fracture is an avulsion injury as a result of forced rotation and lateral bending. This is
potentially an unstable fracture.
Clivus fractures
Fractures of the clivus are described as a result of high-energy impact sustained in motor
vehicle accidents. Longitudinal, transverse, and oblique types have been described in the
literature. A longitudinal fracture carries the worst prognosis, especially when it involves the
vertebrobasilar system. Cranial nerves VI and VII deficits are usually coined with this fracture
type.[14]
Depressed skull fracture
Depressed skull fractures, as shown in the image below, result from a high-energy direct blow to
a small surface area of the skull with a blunt object such as a baseball bat. Comminution of
fragments starts from the point of maximum impact and spreads centrifugally. Most of the
depressed fractures are over the frontoparietal region because the bone is thin and the specific
location is prone to an assailant's attack. A free piece of bone should be depressed greater than
the adjacent inner table of the skull to be of clinical significance and requiring elevation.

Depressed skull fracture (courtesy of Adam Flanders, MD, Thomas

Jefferson University, Philadelphia, Pennsylvania)
A depressed fracture may be open or closed. Open fractures, by definition, have either a skin
laceration over the fracture or the fracture runs through the paranasal sinuses and the middle
ear structures, resulting in communication between the external environment and the cranial
cavity. Open fractures may be clean or contaminated/dirty.
Epidemiology
Frequency
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 (75-90%).
Etiology
In newborns, "ping-pong" depressed fractures are secondary to the baby's head impinging
against the mother's sacral promontory during uterine contractions.[15]The use of forceps also
may cause injury to the skull, but this is rare.
Skull fractures in infants originate from neglect, fall, or abuse. Most of the fractures seen in
children are a result of falls and bicycle accidents. In adults, fractures typically occur from motor
vehicle accidents or violence.
Presentation
Linear skull fracture
Most patients with linear skull fractures are asymptomatic and present without loss of
consciousness. Swelling occurs at the site of impact, and the skin may or may not be breached.
Basilar skull fracture
Patients with fractures of the petrous temporal bone present with CSF otorrhea and bruising
over the mastoids, ie, Battle sign. Presentation with anterior cranial fossa fractures is with CSF
rhinorrhea and bruising around the eyes, ie, "raccoon eyes." Loss of consciousness and
Glasgow Coma Score may vary depending on an associated intracranial pathologic condition.
Longitudinal temporal bone fractures result in ossicular chain disruption and conductive
deafness of greater than 30 dB that lasts longer than 6-7 weeks. Temporary deafness that
resolves in less than 3 weeks is due to hemotympanum and mucosal edema in the middle ear
fossa. Facial palsy, nystagmus, and facial numbness are secondary to involvement of the VII,
VI, and V cranial nerves, respectively. Transverse temporal bone fractures involve the VIII

cranial nerve and the labyrinth, resulting in nystagmus, ataxia, and permanent neural hearing
loss.
Occipital condylar fracture is a very rare and serious injury.[16] Most of the patients with occipital
condylar fracture, especially with type III, are in a coma and have other associated cervical
spinal injuries. These patients may also present with other lower cranial nerve injuries and
hemiplegia or quadriplegia.
Vernet syndrome or jugular foramen syndrome is involvement of the IX, X, and XI cranial nerves
with the fracture. Patients present with difficulty in phonation and aspiration and ipsilateral motor
paralysis of the vocal cord, soft palate (curtain sign), superior pharyngeal constrictor,
sternocleidomastoid, and trapezius.
Collet-Sicard syndrome is occipital condylar fracture with IX, X, XI, and XII cranial nerve
involvement.[17, 18, 19]
Depressed skull fracture
Approximately 25% of patients with depressed skull fracture do not report loss of
consciousness, and another 25% lose consciousness for less than an hour. The presentation
may vary depending on other associated intracranial injuries, such as epidural hematoma, dural
tears, and seizures.

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.

Imaging Studies
Radiographs: 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.
CT scan: CT scan is the criterion standard modality for aiding in the diagnosis of skull fractures.
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.[20]
MRI: MRI or magnetic resonance angiography is of ancillary value for suspected ligamentous
and vascular injuries. Bony injuries are far better visualized using CT scan.
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.
Medical Therapy
Adults with simple linear fractures who are neurologically intact do not require any intervention
and may even be discharged home safely and asked to return if symptomatic. Infants with
simple linear fractures should be admitted for overnight observation regardless of neurological
status. Neurologically intact patients with linear basilar fractures also are treated conservatively,
without antibiotics. Temporal bone fractures are managed conservatively, at least initially,
because tympanic membrane rupture usually heals on its own.

Simple depressed fractures in neurologically intact infants are treated expectantly. These
depressed fractures heal well and smooth out with time, without elevation. Seizure medications
are recommended if the chance of developing seizures is higher than 20%. Open fractures, if
contaminated, may require antibiotics in addition to tetanus toxoid. Sulfisoxazole is a common
recommendation.
Types I and II occipital condylar fractures are treated conservatively with neck stabilization,
which is achieved with a hard (Philadelphia) collar or halo traction.
Surgical Therapy
The role of surgery is limited in the management of skull fractures. Infants and children with
open depressed fractures require surgical intervention. Most surgeons prefer to elevate
depressed skull fractures if the depressed segment is more than 5 mm below the inner table of
adjacent bone. Indications for immediate elevation are gross contamination, dural tear with
pneumocephalus, and an underlying hematoma. At times, craniectomy is performed if the
underlying brain is damaged and swollen. In these instances, cranioplasty is required at a later
date. Another indication for early surgical intervention is an unstable occipital condylar fracture
(type III) that requires atlantoaxial arthrodesis. This can be achieved with inside-outside
fixation.[21]
Delayed surgical intervention is required in ossicular incongruences resulting from a longitudinal
skull base fracture of the temporal bone. Ossiculoplasty may be needed if hearing loss persists
for longer than 3 months or if the tympanic membrane has not healed on its own. Another
indication is persistent CSF leak after a skull base fracture. This requires precise detection of
the site of leak before any surgical intervention is instituted.
Preoperative Details
Blind probing of skull wounds should be avoided. Patients are prepared for surgery, and
exploration is performed in the operating suite under direct vision to prevent loose pieces of
bone from damaging the underlying brain. Patients with open contaminated wounds are treated
with tetanus toxoid and broad-spectrum antibiotics, especially in a delayed presentation.
Intraoperative Details
Overview
To maintain intracranial pressure, mannitol (1 g/kg) may be given at the beginning, and the
PaO2 should be kept at 30-35 mm Hg during the surgery. Patients should be secured firmly to
the table, allowing Trendelenburg or reverse Trendelenburg positioning if required. A lazy "S" or
a horseshoe-shaped incision is made over the depression. A bicoronal incision is preferred for
forehead depressions.
Bony fragments are elevated, and the dura is inspected for any tears. If a dural tear is found, it
should be repaired. Special attention is given to hemostasis to prevent postoperative epidural
collection. Bony fragments are soaked in antibiotic/isotonic sodium chloride solution and are
reassembled. Larger pieces may be wired together. Alternatively, titanium mesh also may be
used to cover the defect. Methyl methacrylate can be used instead of the bone pieces, but this
should be avoided in children. Indeed, absorbable bone plates and screws are recommended
for use in children.
Venous sinus tears
Depressed fracture over a venous sinus poses a unique situation requiring special attention.
The decision to operate is based on the neurological status of the patient, the exact location of
the sinus involved, and the degree of venous flow compromise. A preoperative angiogram with

venous flow phase or magnetic resonance angiography is recommended whenever a

depressed fracture is thought to be over a venous sinus. Useful data regarding the position and
extent of occlusion and transverse sinus dominance is obtained that can affect decisions
regarding surgery.
A neurologically stable patient with a closed depressed fracture over a venous sinus should be
observed. A patient with an open depressed fracture over a patent venous sinus who is
neurologically stable should undergo skin debridement without elevation of the fracture, but if
the patient is neurologically unstable, urgent elevation of the depressed fragment is required.
On the other hand, if the patient is neurologically stable and the sinus is thrombosed, it can be
assumed that ligation of the sinus can be tolerated.
Usually, the anterior one third of the superior sagittal sinus can be ligated without any
consequences; however, tears in the posterior two thirds need repair, either primarily or with a
galea or pericranium patch. Alternatively, a piece of muscle or Gelfoam may be sutured over the
sinus.
Special surgical techniques are used when a skull fracture communicates with mastoid or frontal
air sinuses. The communication of the intracranial space with the outside world needs to be
eliminated.[22]
Postoperative Details
Other than the usual immediate postoperative care, the risk of intracranial hematoma and
venous sinus thrombosis should be kept in mind in contaminated depressed fractures.
Follow-up
Adults with simple linear fractures of the vault, without any loss of consciousness at the time of
initial presentation and with no other complications, do not require long-term follow-up. On the
other hand, infants with similar fractures with dural tears need to be monitored more closely
because of the possibility of the skull fracture expanding.
Patients with contaminated open depressed skull fractures treated surgically should be
monitored with repeat CT scans a few times over the next 2-3 months to check for abscess
formation. Follow-up also is dictated by the complications associated with skull fractures, for
example, seizures, infections, and removal of bone pieces at the time of initial debridement.
Complications
Failure to recognize skull fracture has more consequences than the complications resulting from
treatment. The chance of a concomitant cervical spine injury is 15%, and this should be kept in
mind when assessing a patient with skull fracture.
Linear skull fracture
In infants and children, a simple linear fracture, if associated with a dural tear, can lead to
subepicranial hygroma or a growing skull fracture (leptomeningeal cyst). This may take up to 6
months to develop, resulting from the brain pulsating against a dural defect that is larger than
the bone defect. Repair of such a defect is performed using a split-thickness bone graft.
Growing skull fracture has also been reported in literature following a stab wound to a gravid
abdomen in the last trimester.[23]
A fracture line crossing over a vascular groove, such as the middle meningeal artery, may form
an epidural hematoma.[24] Similarly, a fracture line that crosses over a suture may cause sutural
diastasis.

Basilar skull fracture

The risk of infection is not high, even without routine antibiotics, especially with CSF rhinorrhea.
Facial palsy and ossicular chain disruption associated with basilar fractures are discussed in the
Clinical section. However, notably, facial palsy that starts with a 2- to 3-day delay is secondary
to neurapraxia of the VII cranial nerve and is responsive to steroids, with a good prognosis. A
complete and sudden onset of facial palsy at the time of fracture usually is secondary to nerve
transection, with a poor prognosis.
Other cranial nerves also may be involved in basilar fractures. Fracture of the tip of the petrous
temporal bone may involve the gasserian ganglion. An isolated VI cranial nerve injury is not a
direct result of fracture, but it may be affected secondarily because of tension on the nerve.
Lower cranial nerves (IX, X, XI, and XII) may be involved in occipital condylar fractures, as
described earlier in Vernet and Collet-Sicard syndromes (vide supra). Sphenoid bone fracture
may affect the III, IV, and VI cranial nerves and also may disrupt the internal carotid artery and
potentially result in pseudoaneurysm formation and caroticocavernous fistula (if it involves
venous structures). Carotid injury is suspected in cases in which the fracture runs through the
carotid canal; in these instances, CT-angiography is recommended.
Depressed skull fracture
In addition to the risk of infection in contaminated depressed skull fractures, a risk of developing
seizures also exists. The overall risk of seizures is low but is higher if the patient loses
consciousness for longer than 2 hours, if an associated dural tear is present, and if the seizures
start in the first week of injury.
Outcome and Prognosis
Although skull fractures carry a significant potential risk of cranial nerve and vascular injuries
and direct brain injury, most skull fractures are linear vault fractures in children and are not
associated with epidural hematoma. Most skull fractures, including depressed skull fractures, do
not require surgery. Hence, all of the potential complications listed are associated with a graver
prognosis if the primary fracture is missed during the diagnostic workup.
Future and Controversies
Controversy exists in the use of antibiotics for fractures and the need to elevate a depressed
skull fracture. The use of antibiotics generally is not required unless the open fracture is
obviously contaminated. Similarly, whether to elevate a depressed skull fracture is mostly the
surgeon's choice, dictated by the need for cosmesis.[25]
The use of resorbable bone plates cross-linked with Bone matrix protein-2 (BMP-2) is touted as
a novel method of delivery and may enhance fracture healing.[26]Another delivery system with
scaffolds that deliver plasmid DNA encoding for bone morphogenetic protein-4 (BMP-4) has
been tested in rodents and has shown promise.