Skull Fracture: Types, Causes, and Symptoms

What is a Skull Fracture?

A Skull Fracture, also known as a Cranial Fracture, is a break in the bones that form the skull, which protects the internal organs in the skull cavity, such as the brain, the membranes covering the brain, and blood vessels. The human skull comprises of eight bones held together by sutures that form the neurocranium that houses and protects the brain and fourteen bones that form the facial skeleton or the viscerocranium. A skull fracture is usually the result of direct trauma to the head. These are more common in certain areas, such as over the temples and the skull base, where the bone is thinner.

Is Skull Fracture Condition a Medical Emergency?

Skull Fractures require immediate medical attention to evaluate potential injury to the brain and internal structures.

Types

Skull Fractures may be of the following types:

• Closed fractures occur when there is no penetration of the bone through the overlying skin. Open fractures, on the other hand, happen when there is a penetration of the overlying skin by the bone fragments. Open fractures can be further classified as clean fractures or contaminated/dirty fractures.

The main classification of cranial fracture is as follows:

• Linear fractures: The break in the bone is across its full thickness with no displacement of the bone fragments
• Depressed fractures: The broken bone fragments are displaced inwards; they carry a high risk of increasing the intracranial pressure and damaging internal organs
• Diastatic fractures: These are seen when the break in the bone spreads across the sutures between the adjacent skull bones. These fractures result in the widening of the sutures; they are more common in infants and young children as the sutures have not closed completely
• Basilar fractures: It is a break in the bone at the base of the skull
  • Temporal fracture: It can be subdivided into longitudinal or transverse fractures
  • Occipital condylar fracture: Further subdivided into Types I, II, and III
  • Clivus fracture: Seen in motor vehicle accidents; further subdivided into longitudinal, transverse, and oblique

Some other fractures of the skull that are usually seen in infants and children include:

• Growing fracture: These are seen in children below 3 years due to a growing mass, such as a cyst after a head injury. It is usually seen after an injury to the parietal bone
• Cranial burst fracture: These are seen in infants below 1 year of age with severe head injuries; the brain extends outside the skull and underneath an intact scalp

Causes

Skull fractures are typically caused by direct, blunt force trauma to the skull, which can occur in situations such as motor vehicle accidents or violence. In infants, skull fractures may occur during delivery. In children, skull fractures can result from abuse, neglect, falls, and bicycle accidents.

Signs & Symptoms

The signs and symptoms depend on the type of skull fracture. Linear fractures may not show any symptoms or alteration of neurological functions.
Symptoms and signs, when present, may include the following:

• Swelling at the site of injury
• Loss of consciousness: Present in few
• Leaking of cerebrospinal fluid from the nose
• Bruising around the eyes (raccoon eyes)
• When cranial nerves are involved, the following may be seen:
  • Nystagmus: Abnormal movements of the eyes
  • Ataxia: Lack of muscle coordination
  • Deafness
  • Coma: It is in occipital condylar fractures
  • Quadriplegia: It is in occipital condylar fractures
  • Speech disturbances
  • Swallowing difficulties
• Paralysis of the neck muscles

Investigations

The following investigations are advised for the evaluation of the fractures in addition to a complete neurological examination:

• Laboratory tests:
  • CBP & ESR
  • Metabolic panel
  • Arterial blood gas analysis
  • Tetanus toxoid: In case of open fractures
  • Glucose level and tau transferrin analysis if CSF leak is suspected
• Imaging tests:
  • X-ray of skull and cervical spine
  • CT scan
  • MR angiography: For evaluation of vascular injuries

Diagnosis

A diagnosis of skull fracture is established based on medical history, clinical evaluation, and investigation results.

Treatment options

The treatment of skull fractures depends on the fracture's type, severity, and location. Simple linear fractures and basilar fractures without any signs of neurologic involvement are treated conservatively and monitored for the development of symptoms. Fractures with neurological symptoms are treated with interventions as required.

Medical management

Medical management may include:

• Antibiotics: For the management of open fractures
• Analgesics: For the management of pain
• Mannitol: For maintaining intracranial pressure, especially if surgical interventions are required

Interventional including surgery and indications for surgery

Interventions for the management of skull fractures may include:

• Elevation of depressed fractures
• Craniectomy followed by cranioplasty: If the underlying brain is swollen and damaged
• Inside outside fixation: For occipital condylar fractures
• Ossiculoplasty: For the management of hearing loss that persists for more than 3 months

Role of Diet/ Exercise/ Lifestyle changes/ Preventive

Some measures that can be taken to prevent skull fractures include:

• Use of protective gear while engaging in sporting activities or physical activities with an increased risk of head injuries

Complications

Some complications associated with skull fractures include:

• Formation of epidural hematoma
• Injury to the brain, blood vessels
• Injury to cranial nerves

Prognosis

The prognosis for skull fractures is generally very good, with few requiring interventions or surgical management. In Skull Fractures, including depressed fractures with no neurological involvement, the prognosis is usually very good.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if there is an injury to the head, especially with neurological symptoms.

Indications for hospitalization if required

Depending on the severity of the condition, hospitalization may be required for a few cases of Skull Fractures.

Suggested clinical specialists/ Departments to consult for this condition

Neurology
Neurosurgery
Orthopaedics