Management of Head Injury with Skull Fracture and Minor Intracranial Injury
Patients with skull fracture and minor intracranial injury require hospital admission for neurologic observation and follow-up, as these findings meet criteria for clinically important brain injury (CIBI) that necessitates inpatient monitoring, even when neurologically intact. 1
Initial Assessment and Risk Stratification
The presence of a skull fracture with any intracranial finding automatically elevates the patient beyond "low-risk" status, regardless of Glasgow Coma Scale (GCS) score. According to the 2023 ACEP guidelines, clinically important brain injury is defined as any acute intracranial finding on CT that normally requires hospital admission and neurologic follow-up 1.
What Constitutes "Minor" Intracranial Injury
Clinically unimportant lesions in neurologically intact patients include: 1
- Solitary contusions <5 mm in diameter
- Localized subarachnoid blood <1 mm thick
- Smear subdural hematomas <4 mm thick
- Isolated pneumocephaly
- Closed depressed skull fractures not through the inner table
However, the presence of a skull fracture with ANY intracranial finding warrants admission, as the combination increases risk of deterioration. 2, 3
Hospital Admission and Monitoring Protocol
Mandatory Admission Criteria
All patients with skull fracture plus intracranial injury require: 2, 4
- Hospital admission for minimum 24 hours of observation
- Serial neurologic examinations (every 2-4 hours initially)
- Neurosurgical consultation
- Repeat CT scanning if clinical deterioration occurs
Repeat Imaging Indications
Obtain repeat CT head without contrast if: 2, 5
- Any decline in GCS score
- New or worsening headache
- Persistent or new vomiting
- Development of focal neurologic deficits
- Change in mental status
The risk of delayed hematoma expansion is real—one study documented that all patients requiring neurosurgical intervention had CT diagnosis and transfer preceding clinical deterioration 2.
Special Considerations Based on Fracture Type
Basilar Skull Fracture
Basilar skull fractures require specific management: 6
- Do NOT use prophylactic antibiotics (not recommended by current evidence)
- Monitor for CSF leak (rhinorrhea/otorrhea)
- Consider vascular imaging (CTA) if fracture extends through vascular canal 1
- Risk of meningitis exists but prophylaxis does not reduce this risk
Open or Depressed Skull Fracture
Open-depressed fractures require: 6
- Operative debridement and thorough irrigation (best means of preventing infection)
- Neurosurgical intervention for depression through inner table
- Tetanus prophylaxis update
Neurosurgical Intervention Criteria
Indications for neurosurgical operation include: 2, 4
- Clinical deterioration (declining GCS)
- Significant lesion volume with mass effect
- Midline shift on CT
- Compressed third ventricle or basal cisterns
- Depressed skull fracture through inner table
In one series, 40 of 113 patients transferred to neurosurgery required operation, primarily for epidural hematomas 2. Skull fracture significantly increases the likelihood of finding intracranial lesions requiring intervention 3.
Discharge Criteria and Follow-up
Patients may be considered for discharge only after: 4
- Minimum 24 hours of stable neurologic examination
- No progression on repeat imaging (if obtained)
- Reliable home situation with capable observer
- Clear return precautions provided
- Neurosurgical follow-up arranged within 1-2 weeks
Critical Discharge Instructions
Patients/families must return immediately for: 4
- Worsening headache
- Repeated vomiting
- Confusion or difficulty awakening
- Seizure activity
- Weakness or numbness
- Vision changes
Common Pitfalls to Avoid
Do not rely on skull X-ray alone—up to 50% of intracranial injuries occur without fracture, and conversely, not all fractures are evident on plain films 1, 5. CT head without contrast is the gold standard for evaluation 1.
Do not discharge patients with skull fracture and intracranial findings based solely on normal GCS—the combination warrants admission even in asymptomatic patients, as delayed deterioration can occur 2, 3.
Do not assume "minor" intracranial injury is benign in the presence of skull fracture—the fracture indicates significant force transmission and increases risk of delayed complications 3.
Anticoagulated or Coagulopathic Patients
For patients on anticoagulation or with coagulopathy: 4
- Mandatory hospital admission regardless of lesion size
- Repeat CT scan before discharge even if initial CT shows minimal findings
- Consider reversal of anticoagulation in consultation with neurosurgery
- Extended observation period (>24 hours) recommended