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{{Infobox medical condition (new)
{{DiseaseDisorder infobox |
Name = Skull fracture | | name = Skull fracture
Image = Depressed skull fracture.jpg | | image = Depressed skull fracture.jpg
Caption = A piece of a skull with a depressed skull fracture | | caption = A piece of a ] with a depressed skull fracture
| pronounce =
ICD10 = S02 |
| field =
ICD9 = {{ICD9|800.0}}-{{ICD9|804.9}} |
| synonyms =
MeshID = D012887 |
| symptoms =
| complications =
| onset =
| duration =
| types =
| causes =
| risks =
| diagnosis =
| differential =
| prevention =
| treatment =
| medication =
| prognosis =
| frequency =
| deaths =
}} }}


A '''skull fracture''' is a break in one or more of the eight bones that form the cranial portion of the ], usually occurring as a result of ]. If the force of the impact is excessive, the ] may fracture at or near the site of the impact and cause damage to the underlying structures within the skull such as the ], ]s, and ].
] showing a summary of ]]]
A '''skull fracture''' is a break in one or more of the bones in the ] usually occurring as a result of ]. If the force of the impact is excessive the ] may fracture at or near the site of the impact. The force of direct impact may cause damage to the underlying physical structures contained within the skull such as the membranes, ], and ], even in the absence of a fracture. While an uncomplicated skull fracture can occur without associated physical or ] damage and is in itself usually not clinically significant, a fracture in healthy bone indicates that a substantial amount of force has been applied and increases the possibility of associated ]. Any significant blow to the head results in a ], with or without loss of ].


While an uncomplicated skull fracture can occur without associated physical or ] damage and is in itself usually not clinically significant, a fracture in healthy bone indicates that a substantial amount of force has been applied and increases the possibility of associated ]. Any significant blow to the head results in a ], with or without loss of ].
A fracture which occurs in conjunction with an overlying ] which tears the ], is termed a compound fracture.


A fracture in conjunction with an overlying ] that tears the ] and the ], or runs through the ] and the ] structures, bringing the outside environment into contact with the cranial cavity is called a compound fracture. Compound fractures can either be clean or contaminated.
The presence of a concussion or skull fracture in trauma patients without intracranial ] or focal neurologic deficits was indicted in long term cognitive impairments and emotional lability at nearly double the rate as those patients without either complication.<ref>Jackson JC. J Trauma. 2007 Jan;62(1):80-8. Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage.PMID 17215737</ref>


There are four major types of skull fractures: linear, depressed, diastatic, and basilar. Linear fractures are the most common, and usually require no intervention for the fracture itself. Depressed fractures are usually ], with broken portions of bone displaced inward—and may require surgical intervention to repair underlying tissue damage. Diastatic fractures widen the sutures of the skull and usually affect children under three. Basilar fractures are in the bones at the base of the skull.
In one study of emergency room patients at a teaching hospital who were suspected of having suffered a closed head injury completed ] testing and had normal ] (CT) scans, they did not differ in CHI scores as measured by the ] (GCS). Those with a skull fracture were shown to have "neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS".<ref>Smith-Seemiller L. Brain Inj. 1997 Mar;11(3):191-6. Impact of skull fracture on neuropsychological functioning following closed head injury. PMID 9058000</ref>
{{TOC limit}}


==Types==
There are four major types of skull fractures; linear fractures which are the most common and usually require no intervention for the fracture itself, depressed fractures which are usually comminuted with broken portions of bone displaced inward may require surgical intervention if there is underlying tissue damage, diastatic fractures in which the sutures of the skull widen usually affects children under three, and basilar fracture which occur in the bone at the base of the skull.
==Linear fracture==
]
'''Linear skull fractures''' are breaks in the bone that transverse the full thickness of the skull from the outer to inner table, are usually fairly straight and involve no displacement of the bone. The common method of injury is blunt force trauma in which the energy from the blow is transferred over a wide surface area of the skull. Linear fractures of the skull are usually of little clinical significance unless they parallel in close proximity or transverse a suture, or they involve a venous sinus groove or vascular channel. The resulting complications may include suture diastisis, venous sinus thrombosis, and epidural hematoma. In young children although rare the possibility exists of developing a growing skull fracture especially if the fracture occurs in the parietal bone.<ref>Haar FL. Complication of linear skull fracture in young children. Am J Dis Child. 1975 Oct;129(10):1197-200. PMID 1190143</ref>
{{clear}}


==Depressed skull fracture== ===Linear fracture===
Linear skull fractures are breaks in the bone that transverse the full thickness of the skull from the outer to inner table. They are usually fairly straight with no bone displacement. The common cause of injury is blunt force trauma where the impact energy transferred over a wide area of the skull.{{citation needed|date=October 2020}}
]

A '''Depressed skull fracture''', is a type of fracture usually resulting from blunt force trauma, such as getting struck with a hammer, rock or getting kicked in the head. This type of fracture which occurs in 11% of severe head injuries, are comminuted fractures in which broken bones are displaced inward. This type of fracture carries a high risk of increasing ], crushing the delicate tissue. Compound depressed skull fractures occur when there is a laceration over the fracture, resulting in the internal cranial cavity being in contact with the outside environment increasing the risk of contamination and infection. Complex depressed fractures are those in which the ] is torn. Depressed skull fractures may require ] to lift the bones off the brain if they are causing pressure on it.<ref name="singh">Singh J and Stock A. 2006. Emedicine.com. Retrieved on January 26, 2007.</ref>
Linear skull fractures are usually of little clinical significance unless they parallel in close proximity or transverse a ], or they involve a venous sinus groove or vascular channel. The resulting complications may include suture ], ], and ]. In young children, although rare, the possibility exists of developing a growing skull fracture especially if the fracture occurs in the ].<ref>{{cite journal | pmid = 1190143 | volume=129 | title=Complication of linear skull fracture in young children | date=October 1975 | author=Haar FL | journal=Am. J. Dis. Child. | issue=10 | pages=1197–200 | doi=10.1001/archpedi.1975.02120470047013 }}</ref>
{{clear}}

==Diastatic skull fracture==
===Depressed fracture===
]
]
'''Diastatic fractures''' occur when the fracture line transverses
A depressed skull fracture is a type of fracture usually resulting from blunt force trauma, such as getting struck with a hammer, rock or getting kicked in the head. These types of fractures—which occur in 11% of severe head injuries—are comminuted fractures in which broken bones displace inward. Depressed skull fractures present a high risk of increased ], or a hemorrhage to the brain that crushes the delicate tissue.{{citation needed|date=October 2020}}
one or more sutures of the skull causing a widening of the suture. While this type of fracture is usually seen in infants and young children as the sutures are not yet fused it can also occur in adults. When a diastatic fracture occurs in adults it usually affects the lamboidal suture as this suture does not fully fuse in adults until about the age of 60. Diastatic fractures can occur with different types of fractures and it is also possible for diastasis of the cranial sutures to occur without a concomitant fracture. Sutural diastasis may also occur in various congenital disorders such as ] and ].<ref>Paterson CR, Burns J, McAllion SJ. Am J Med Genet. 1993 Jan 15;45(2):187-92.Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form.

PMID 8456801</ref><ref>Kanda M, Kabe S, Kanki T, Sato J, Hasegawa Y. Cleidocranial dysplasia: a case report No Shinkei Geka. 1997 Dec;25(12):1109-13. PMID 9430147</ref><ref>Sabini RC, Elkowitz DE. J Am Osteopath Assoc. 2006 Oct;106(10):600-4. Significance of differences in patency among cranial sutures.PMID 17122029</ref><ref>Pirouzmand F, Muhajarine N. Craniofac Surg. 2008 Jan;19(1):27-36. Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. PMID 18216661</ref>
Compound depressed skull fractures occur when there is a laceration over the fracture, putting the internal cranial cavity in contact with the outside environment, increasing the risk of contamination and infection. In complex depressed fractures, the ] is torn. Depressed skull fractures may require ] to lift the bones off the brain if they are pressing on it by making burr holes on the adjacent normal skull.<ref name="singh">Singh J and Stock A. 2006. Emedicine.com. Retrieved on January 26, 2007.</ref>
{{clear}}

==Basilar skull fracture==
===Diastatic fracture===
]
Diastatic fractures occur when the fracture line transverses one or more sutures of the skull causing a widening of the suture. While this type of fracture is usually seen in infants and young children as the sutures are not yet fused it can also occur in adults. When a diastatic fracture occurs in adults it usually affects the ] as this suture does not fully fuse in adults until about the age of 60. Most adult diastatic fractures are caused by severe head injuries. Due to the trauma, diastatic fracture occurs with the collapse of the surrounding head bones. It crushes the delicate tissue, similarly to a depressed skull fracture.{{citation needed|date=August 2021}}

Diastatic fractures can occur with different types of fractures and it is also possible for diastasis of the cranial sutures to occur without a concomitant fracture. Sutural diastasis may also occur in various congenital disorders such as ] and ].<ref>{{cite journal | pmid = 8456801 | doi=10.1002/ajmg.1320450208 | volume=45 | title=Osteogenesis imperfecta: the distinction from child abuse and the recognition of a variant form | date=January 1993 | author=Paterson CR, Burns J, McAllion SJ | journal=Am. J. Med. Genet. | issue=2 | pages=187–92 }}</ref><ref>{{cite journal | pmid = 9430147 | volume=25 | title= | date=December 1997 | author=Kanda M, Kabe S, Kanki T, Sato J, Hasegawa Y | journal=No Shinkei Geka | issue=12 | pages=1109–13 }}</ref><ref>{{cite journal | pmid = 17122029 | volume=106 | title=Significance of differences in patency among cranial sutures | date=October 2006 | author=Sabini RC, Elkowitz DE | journal=J Am Osteopath Assoc | issue=10 | pages=600–4 }}</ref><ref>{{cite journal | pmid = 18216661 | doi=10.1097/SCS.0b013e31815ca07a | volume=19 | title=Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology | date=January 2008 | author=Pirouzmand F, Muhajarine N | journal=J Craniofac Surg | issue=1 | pages=27–36 | s2cid=7154559 }}</ref>

===Basilar fracture===
{{main|Basilar skull fracture}} {{main|Basilar skull fracture}}
]
]s, breaks in bones at the base of the skull, require more force to cause than cranial vault fractures. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients. Basilar fractures have characteristic signs: blood in the ]; a clear fluid called ] (CSF) leaking from the nose or ears; ] (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and ] (caused when blood collects behind the ears and causes bruising).
]s are linear fractures that occur in the floor of the cranial vault (skull base), which require more force to cause than other areas of the neurocranium. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients.


Basilar fractures have characteristic signs: blood in the ]; ] (] leaking from the nose) or from the ears (cerebrospinal fluid otorrhea); ] ] often called ']'<ref>{{cite journal | pmid = 11754879 | volume=32 | title='Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture | date=December 2001 | author=Herbella FA, Mudo M, Delmonti C, Braga FM, Del Grande JC | journal=Injury | issue=10 | pages=745–7 | doi=10.1016/s0020-1383(01)00144-9 }}</ref> (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and retro] ecchymosis known as "]" (bruising over the mastoid process).<ref>{{cite journal | author = Tubbs RS, Shoja MM, Loukas M | display-authors = etal | date = Jan 2010 | title = William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture | journal = J Neurosurg | volume = 112 | issue = 1| pages = 186–8 | pmid = 19392601 | doi = 10.3171/2008.8.JNS08241 }}</ref>
==Growing skull fracture==

A '''growing skull fracture''' (GSF) also known as a craniocerebral erosion or leptomeningeal cyst due to the usual development of a cystic mass filled with cerebral spinal fluid is a rare complication of head injury usually associated with linear skull fractures of the parietal bone in children under 3. It has been reported in older children in atypical regions of the skull such as the basiooccipital and the base of the skull base and in association with other types of skull fractures. It is characterized by a diastatic enlargement of the fracture. There are various factors associated with the development of a GSF with the primary causitive factor being a tear in the ]. The skull fracture enlarges due in part to the rapid physiologic growth of the brain which occurs in young children and brain cerebrospinal fluid (CSF) pulsations in the underlying leptomenigeal cystic mass.
===Growing fracture===
<ref>Gupta SK, Reddy NM, Khosla VK, Mathuriya SN, Shama BS, Pathak A, Tewari MK, Kak VK. Growing skull fractures: a clinical study of 41 patients. Acta Neurochir (Wien). 1997;139(10):928-32.
A growing skull fracture (GSF) also known as a craniocerebral erosion or leptomeningeal cyst<ref>{{cite journal | pmid = 20496339 | volume=29 | title=Leptomeningeal cyst in a child after head trauma: a case report | year=2010 | author=Irabor PF, Akhigbe AO | journal=West Afr J Med | issue=1 | pages=44–6 }}</ref> due to the usual development of a cystic mass filled with cerebrospinal fluid is a rare complication of head injury usually associated with linear skull fractures of the parietal bone in children under 3. It has been reported in older children in atypical regions of the skull such as the basioccipital and the base of the skull base and in association with other types of skull fractures. It is characterized by a diastatic enlargement of the fracture.{{citation needed|date=August 2021}}
PMID 9401652</ref><ref>Ersahin Y, Gülmen V, Palali I, Mutluer S. Growing skull fractures (craniocerebral erosion). Neurosurg Rev. 2000 Sep;23(3):139-44. PMID 11086738</ref><ref>Muhonen MG, Piper JG, Menezes AH. Surg Neurol. 1995 Apr;43(4):367-72; discussion 372-3. Pathogenesis and treatment of growing skull fractures.PMID 7792708</ref><ref>Caffo M, Germanò A, Caruso G, Meli F, Calisto A, Tomasello F. Acta Neurochir (Wien). 2003 Mar;145(3):201-8; discussion 208. Growing skull fracture of the posterior cranial fossa and of the orbital roof. PMID 12632116</ref><ref>Ziyal IM, Aydin Y, Türkmen CS, Salas E, Kaya AR, Ozveren F. Acta Neurochir (Wien). 1998;140(7):651-4. The natural history of late diagnosed or untreated growing skull fractures: report on two cases.PMID 9781277</ref><ref>Locatelli D, Messina AL, Bonfanti N, Pezzotta S, Gajno TM. Growing fractures: an unusual complication of head injuries in pediatric patients. Neurochirurgia (Stuttg). 1989 Jul;32(4):101-4. PMID 2770958</ref><ref>Pezzotta S, Silvani V, Gaetani P, Spanu G, Rondini G. J Neurosurg Sci. 1985 Apr-Jun;29(2):129-35. Growing skull fractures of childhood. Case report and review of 132 cases. PMID 4093801</ref>

Various factors are associated with the development of a GSF. The primary causative factor is a tear in the ]. The skull fracture enlarges due, in part, to the rapid physiologic growth of the brain that occurs in young children, and brain ] (CSF) pulsations in the underlying ] ]ic mass.<ref>{{cite journal | pmid = 9401652 | volume=139 | title=Growing skull fractures: a clinical study of 41 patients | year=1997 | author=Gupta SK, Reddy NM, Khosla VK | display-authors = etal | journal=Acta Neurochir (Wien) | issue=10 | pages=928–32 | doi=10.1007/bf01411301 | s2cid=24991254 }}</ref><ref>{{cite journal | pmid = 11086738 | volume=23 | title=Growing skull fractures (craniocerebral erosion) | date=September 2000 | author=Ersahin Y, Gülmen V, Palali I, Mutluer S | journal=Neurosurg Rev | issue=3 | pages=139–44 | doi=10.1007/pl00011945 | s2cid=22659384 }}</ref><ref>{{cite journal | pmid = 7792708 | volume=43 | title=Pathogenesis and treatment of growing skull fractures | date=April 1995 | author=Muhonen MG, Piper JG, Menezes AH | journal=Surg Neurol | issue=4 | pages=367–72; discussion 372–3 | doi=10.1016/0090-3019(95)80066-p }}</ref><ref>{{cite journal | pmid = 12632116 | doi=10.1007/s00701-002-1054-y | volume=145 | title=Growing skull fracture of the posterior cranial fossa and of the orbital roof | date=March 2003 | author=Caffo M, Germanò A, Caruso G, Meli F, Calisto A, Tomasello F | journal=Acta Neurochir (Wien) | issue=3 | pages=201–8; discussion 208 | s2cid=5665654 }}</ref><ref>{{cite journal | pmid = 9781277 | volume=140 | title=The natural history of late diagnosed or untreated growing skull fractures: report on two cases | year=1998 | author=Ziyal IM, Aydin Y, Türkmen CS, Salas E, Kaya AR, Ozveren F | journal=Acta Neurochir (Wien) | issue=7 | pages=651–4 | doi=10.1007/s007010050158 | s2cid=18879100 }}</ref><ref>{{cite journal | pmid = 2770958 | doi=10.1055/s-2008-1054014 | volume=32 | title=Growing fractures: an unusual complication of head injuries in pediatric patients | date=July 1989 | author=Locatelli D, Messina AL, Bonfanti N, Pezzotta S, Gajno TM | journal=Neurochirurgia (Stuttg) | issue=4 | pages=101–4 | s2cid=44468528 }}</ref><ref>{{cite journal | pmid = 4093801 | volume=29 | title=Growing skull fractures of childhood. Case report and review of 132 cases | year=1985 | author=Pezzotta S, Silvani V, Gaetani P, Spanu G, Rondini G | journal=J Neurosurg Sci | issue=2 | pages=129–35 }}</ref>

====Cranial burst fracture====
A cranial burst skull fracture, usually occurring with severe injuries in infants less than 1 year of age, is a closed, diastatic skull fracture with cerebral extrusion beyond the outer table of the skull under the intact ].{{citation needed|date=August 2021}}

Acute scalp swelling is associated with this type of fracture. In equivocal cases without immediate scalp swelling the diagnosis may be made via the use of ] thus insuring more prompt treatment and avoiding the development of a "growing skull fracture".<ref>{{cite journal | pmid = 8750951 | volume=11 | title=Cranial burst fracture in infants: acute recognition and management | date=December 1995 | author=Donahue DJ, Sanford RA, Muhlbauer MS, Chadduck WM | journal=Childs Nerv Syst | issue=12 | pages=692–7 | doi=10.1007/BF00262233 | s2cid=26744592 }}</ref>

===Compound fracture===
] to the ] allowing outside environmental contact with the skull cavity.]]
A fracture in conjunction with an overlying ] that tears the epidermis and the ]—or runs through the ] and the ] structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.{{citation needed|date=August 2021}}

Compound fractures may either be clean or contaminated. Intracranial air (]) may occur in compound skull fractures.<ref>Fundamentals of diagnostic radiology by William E. Brant, Clyde A. Helms p.56</ref>

The most serious complication of compound skull fractures is infection. Increased risk factors for infection include visible contamination, meningeal tear, loose bone fragments and presenting for treatment more than eight hours after initial injury.<ref>{{cite journal | author = Rehman L, Ghani E, Hussain A | display-authors = etal | date = Mar 2007 | title = Infection in compound depressed fracture of the skull | journal = J Coll Physicians Surg Pak | volume = 17 | issue = 3| pages = 140–3 | pmid = 17374298 }}</ref>

====Compound elevated fracture====
A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull. This type of skull fracture is always compound in nature. It can be caused during an assault with a weapon where the initial blow penetrates the skull and the underlying meninges and, on withdrawal, the weapon lifts the fractured portion of the skull outward. It can also be caused by the skull rotating while being struck in a case of blunt force trauma, the skull rotating while striking an object as in a fall, or it may occur during transfer of a patient after an initial compound head injury.<ref>Elevated skull fracture</ref><ref>{{cite journal | pmid = 16630918 | doi=10.1016/j.surneu.2005.07.010 | volume=65 | title=Compound elevated skull fracture: a forgotten type of skull fracture | date=May 2006 | author=Adeolu AA, Shokunbi MT, Malomo AO, Komolafe EO, Olateju SO, Amusa YB | journal=Surg Neurol | issue=5 | pages=503–5 }}</ref>

==Anatomy==
{{multiple image
| align = right
| direction = horizontal
| image1 = Cranial bones en.svg
| width1 = 208
| caption1 = ] of the human skull with the ] highlighted
| image2 = Three bone layers of the cranial vault.jpg
| width2 = 290
| caption2 = The three bone layers of the skull
}}
The human skull is anatomically divided into two parts: the ], formed by eight cranial bones that houses and protect the brain—and the facial skeleton (]) composed of fourteen bones, not including the three ]s of the inner ear.<ref>Anne M. Gilroy: : Atlas of Anatomy. P.454; Thime Medical Publishers Inc. (2008) {{ISBN|1-60406-151-0}}</ref> The term ''skull fracture'' typically means fractures to the neurocranium, while fractures of the facial portion of the skull are '']s'', or if the jaw is fractured, a '']''.<ref>{{cite journal | pmid = 6950035 | volume=40 | title=Fractures of the mandible: a review of 580 cases | date=January 1982 | author=Olson RA, Fonseca RJ, Zeitler DL, Osbon DB | journal=J. Oral Maxillofac. Surg. | issue=1 | pages=23–8 | doi=10.1016/s0278-2391(82)80011-6 }}</ref>

The eight cranial bones are separated by ]s: one ], two ]s, two ]s, one ], one ], and one ].<ref>Leon Schlossberg, George D. Zuidema, Johns: The Johns Hopkins Atlas of Human Functional Anatomy, p.5; The Johns Hopkins University Press; (1997) {{ISBN|0-8018-5652-3}}</ref>

The bones of the skull are in three layers: the hard compact layer of the external table ('']''), the ] (a spongy layer of ] in the middle, and the compact layer of the inner table (''Lamina interna'').<ref>Johannes Lang: Skull base and related structures: atlas of clinical anatomy. P.208. F.K.Schattauer, Germany;(July 1999) {{ISBN|3-7945-1947-7}}</ref>

Skull thickness is variable, depending on location. Thus the traumatic impact required to cause a fracture depends on the impact site. The skull is thick at the ], the ], the ]es, and the external angular process of the frontal bone. Areas of the skull that are covered with muscle have no underlying diploë formation between the internal and external lamina, which results in thin bone more susceptible to fractures.{{citation needed|date=August 2021}}

Skull fractures occur more easily at the thin squamous ] and ]s, the ], the ] (the opening at the base of the skull that the spinal cord passes through), the ], and the inner portions of the ] at the base of the skull. The ], a depression at the base of the cranial cavity forms the thinnest part of the skull and is thus the weakest part. This area of the cranial floor is weakened further by the presence of multiple ]; as a result this section is at higher risk for basilar skull fractures to occur. Other areas more susceptible to fractures are the ], the roof of orbits in the ], and the areas between the mastoid and ]es in the ].<ref>]: Ali Nawaz Khan: Imaging in Skull Fractures </ref>

==Prognosis==
Children with a simple skull fracture without other concerns are at low risk of a bad outcome and rarely require aggressive treatment.<ref>{{cite journal|last1=Bressan|first1=S|last2=Marchetto|first2=L|last3=Lyons|first3=TW|last4=Monuteaux|first4=MC|last5=Freedman|first5=SB|last6=Da Dalt|first6=L|last7=Nigrovic|first7=LE|title=A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children|journal=Annals of Emergency Medicine|volume=71|issue=6|pages=714–724.e2|date=23 November 2017|doi=10.1016/j.annemergmed.2017.10.014|pmid=29174834|s2cid=205548333|pmc=10052777}}</ref>

The presence of a concussion or skull fracture in people after trauma without intracranial ] or ] was indicated in long term cognitive impairments and emotional lability at nearly double the rate as those patients without either complication.<ref>{{cite journal | pmid = 17215737 | doi=10.1097/TA.0b013e31802ce9bd | volume=62 | title=Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage | date=January 2007 | author=Jackson JC, Obremskey W, Bauer R | display-authors = etal | journal=J Trauma | issue=1 | pages=80–8}}</ref>

Those with a skull fracture were shown to have "neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS".<ref>{{cite journal | pmid = 9058000 | volume=11 | title=Impact of skull fracture on neuropsychological functioning following closed head injury | date=March 1997 | author=Smith-Seemiller L, Lovell MR, Smith S, Markosian N, Townsend RN | journal=Brain Inj | issue=3 | pages=191–6 | doi=10.1080/026990597123638}}</ref>

==See also==
* ]
* ]
* ]


==References== ==References==
{{reflist|2}} {{Reflist}}

==Bibliography== ==Bibliography==
*Forensic Neuropathology By Jan E. Leestma Publisher: CRC Press; 2 edition (October 14, 2008) Language: English ISBN 0849391679 ISBN 978-0849391675 * Forensic Neuropathology By Jan E. Leestma Publisher: CRC Press; 2 edition (October 14, 2008) Language: English {{ISBN|0-8493-9167-9}} {{ISBN|978-0849391675}}
*Neuroimaging: Clinical and Physical Principles By Robert A. Zimmerman, Wendell A. Gibby, Raymond F. Carmody Publisher: Springer; 1st edition (January 15, 2000) Language: English ISBN- 0387949631 ISBN 978-0387949635 * Neuroimaging: Clinical and Physical Principles By Robert A. Zimmerman, Wendell A. Gibby, Raymond F. Carmody Publisher: Springer; 1st edition (January 15, 2000) Language: English {{ISBN|0387949631}} {{ISBN|978-0-387-94963-5}}

==External links==
== External links ==
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{{Medical resources
*
| ICD10 = S02
| ICD9 = {{ICD9|800.0}}-{{ICD9|804.9}}
| DiseasesDB=12169
| MedlinePlus = 000060
| MeshID = D012887
}}


{{Fractures}} {{Fractures}}
{{Authority control}}


{{DEFAULTSORT:Skull Fracture}}
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Latest revision as of 04:49, 18 October 2024

Medical condition
Skull fracture
A piece of a skull with a depressed skull fracture
SpecialtyEmergency medicine Edit this on Wikidata

A skull fracture is a break in one or more of the eight bones that form the cranial portion of the skull, usually occurring as a result of blunt force trauma. If the force of the impact is excessive, the bone may fracture at or near the site of the impact and cause damage to the underlying structures within the skull such as the membranes, blood vessels, and brain.

While an uncomplicated skull fracture can occur without associated physical or neurological damage and is in itself usually not clinically significant, a fracture in healthy bone indicates that a substantial amount of force has been applied and increases the possibility of associated injury. Any significant blow to the head results in a concussion, with or without loss of consciousness.

A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges, or runs through the paranasal sinuses and the middle ear structures, bringing the outside environment into contact with the cranial cavity is called a compound fracture. Compound fractures can either be clean or contaminated.

There are four major types of skull fractures: linear, depressed, diastatic, and basilar. Linear fractures are the most common, and usually require no intervention for the fracture itself. Depressed fractures are usually comminuted, with broken portions of bone displaced inward—and may require surgical intervention to repair underlying tissue damage. Diastatic fractures widen the sutures of the skull and usually affect children under three. Basilar fractures are in the bones at the base of the skull.

Types

Linear fracture

Linear skull fractures are breaks in the bone that transverse the full thickness of the skull from the outer to inner table. They are usually fairly straight with no bone displacement. The common cause of injury is blunt force trauma where the impact energy transferred over a wide area of the skull.

Linear skull fractures are usually of little clinical significance unless they parallel in close proximity or transverse a suture, or they involve a venous sinus groove or vascular channel. The resulting complications may include suture diastasis, venous sinus thrombosis, and epidural hematoma. In young children, although rare, the possibility exists of developing a growing skull fracture especially if the fracture occurs in the parietal bone.

Depressed fracture

Depressed skull fracture

A depressed skull fracture is a type of fracture usually resulting from blunt force trauma, such as getting struck with a hammer, rock or getting kicked in the head. These types of fractures—which occur in 11% of severe head injuries—are comminuted fractures in which broken bones displace inward. Depressed skull fractures present a high risk of increased pressure on the brain, or a hemorrhage to the brain that crushes the delicate tissue.

Compound depressed skull fractures occur when there is a laceration over the fracture, putting the internal cranial cavity in contact with the outside environment, increasing the risk of contamination and infection. In complex depressed fractures, the dura mater is torn. Depressed skull fractures may require surgery to lift the bones off the brain if they are pressing on it by making burr holes on the adjacent normal skull.

Diastatic fracture

Cranial abnormalities in cleidocranial dysplasia including diastatic sutures

Diastatic fractures occur when the fracture line transverses one or more sutures of the skull causing a widening of the suture. While this type of fracture is usually seen in infants and young children as the sutures are not yet fused it can also occur in adults. When a diastatic fracture occurs in adults it usually affects the lambdoidal suture as this suture does not fully fuse in adults until about the age of 60. Most adult diastatic fractures are caused by severe head injuries. Due to the trauma, diastatic fracture occurs with the collapse of the surrounding head bones. It crushes the delicate tissue, similarly to a depressed skull fracture.

Diastatic fractures can occur with different types of fractures and it is also possible for diastasis of the cranial sutures to occur without a concomitant fracture. Sutural diastasis may also occur in various congenital disorders such as cleidocranial dysplasia and osteogenesis imperfecta.

Basilar fracture

Main article: Basilar skull fracture
Superior view of the skull base

Basilar skull fractures are linear fractures that occur in the floor of the cranial vault (skull base), which require more force to cause than other areas of the neurocranium. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients.

Basilar fractures have characteristic signs: blood in the sinuses; cerebrospinal fluid rhinorrhea (CSF leaking from the nose) or from the ears (cerebrospinal fluid otorrhea); periorbital ecchymosis often called 'raccoon eyes' (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and retroauricular ecchymosis known as "Battle's sign" (bruising over the mastoid process).

Growing fracture

A growing skull fracture (GSF) also known as a craniocerebral erosion or leptomeningeal cyst due to the usual development of a cystic mass filled with cerebrospinal fluid is a rare complication of head injury usually associated with linear skull fractures of the parietal bone in children under 3. It has been reported in older children in atypical regions of the skull such as the basioccipital and the base of the skull base and in association with other types of skull fractures. It is characterized by a diastatic enlargement of the fracture.

Various factors are associated with the development of a GSF. The primary causative factor is a tear in the dura mater. The skull fracture enlarges due, in part, to the rapid physiologic growth of the brain that occurs in young children, and brain cerebrospinal fluid (CSF) pulsations in the underlying leptomeningeal cystic mass.

Cranial burst fracture

A cranial burst skull fracture, usually occurring with severe injuries in infants less than 1 year of age, is a closed, diastatic skull fracture with cerebral extrusion beyond the outer table of the skull under the intact scalp.

Acute scalp swelling is associated with this type of fracture. In equivocal cases without immediate scalp swelling the diagnosis may be made via the use of magnetic resonance imaging thus insuring more prompt treatment and avoiding the development of a "growing skull fracture".

Compound fracture

Compound skull fractures occur when all layers protecting the brain have been breached from the epidermis to the meninges allowing outside environmental contact with the skull cavity.

A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges—or runs through the paranasal sinuses and the middle ear structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.

Compound fractures may either be clean or contaminated. Intracranial air (pneumocephalus) may occur in compound skull fractures.

The most serious complication of compound skull fractures is infection. Increased risk factors for infection include visible contamination, meningeal tear, loose bone fragments and presenting for treatment more than eight hours after initial injury.

Compound elevated fracture

A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull. This type of skull fracture is always compound in nature. It can be caused during an assault with a weapon where the initial blow penetrates the skull and the underlying meninges and, on withdrawal, the weapon lifts the fractured portion of the skull outward. It can also be caused by the skull rotating while being struck in a case of blunt force trauma, the skull rotating while striking an object as in a fall, or it may occur during transfer of a patient after an initial compound head injury.

Anatomy

Lateral view of the human skull with the neurocranium highlightedThe three bone layers of the skull

The human skull is anatomically divided into two parts: the neurocranium, formed by eight cranial bones that houses and protect the brain—and the facial skeleton (viscerocranium) composed of fourteen bones, not including the three ossicles of the inner ear. The term skull fracture typically means fractures to the neurocranium, while fractures of the facial portion of the skull are facial fractures, or if the jaw is fractured, a mandibular fracture.

The eight cranial bones are separated by sutures: one frontal bone, two parietal bones, two temporal bones, one occipital bone, one sphenoid bone, and one ethmoid bone.

The bones of the skull are in three layers: the hard compact layer of the external table (lamina externa), the diploë (a spongy layer of red bone marrow in the middle, and the compact layer of the inner table (Lamina interna).

Skull thickness is variable, depending on location. Thus the traumatic impact required to cause a fracture depends on the impact site. The skull is thick at the glabella, the external occipital protuberance, the mastoid processes, and the external angular process of the frontal bone. Areas of the skull that are covered with muscle have no underlying diploë formation between the internal and external lamina, which results in thin bone more susceptible to fractures.

Skull fractures occur more easily at the thin squamous temporal and parietal bones, the sphenoid sinus, the foramen magnum (the opening at the base of the skull that the spinal cord passes through), the petrous temporal ridge, and the inner portions of the sphenoid wings at the base of the skull. The middle cranial fossa, a depression at the base of the cranial cavity forms the thinnest part of the skull and is thus the weakest part. This area of the cranial floor is weakened further by the presence of multiple foramina; as a result this section is at higher risk for basilar skull fractures to occur. Other areas more susceptible to fractures are the cribriform plate, the roof of orbits in the anterior cranial fossa, and the areas between the mastoid and dural sinuses in the posterior cranial fossa.

Prognosis

Children with a simple skull fracture without other concerns are at low risk of a bad outcome and rarely require aggressive treatment.

The presence of a concussion or skull fracture in people after trauma without intracranial hemorrhage or focal neurologic deficits was indicated in long term cognitive impairments and emotional lability at nearly double the rate as those patients without either complication.

Those with a skull fracture were shown to have "neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS".

See also

References

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  20. Elevated skull fracture
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Bibliography

  • Forensic Neuropathology By Jan E. Leestma Publisher: CRC Press; 2 edition (October 14, 2008) Language: English ISBN 0-8493-9167-9 ISBN 978-0849391675
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