Management and Treatment of Skull Fractures
Immediate Diagnostic Approach
All patients with suspected skull fractures require non-contrast head CT scanning as the primary diagnostic modality, as CT is superior to skull radiographs for detecting both fractures and associated intracranial injuries. 1, 2
Key Diagnostic Principles
- Skull radiographs should not be used for diagnosis or screening of intracranial complications, as they have only 63% sensitivity for detecting skull fractures and cannot identify intracranial hemorrhage, edema, or mass effect 1
- CT scanning is mandatory because 68% of patients with positive CT findings have skull fractures, and the presence of a skull fracture increases the risk of requiring neurosurgical intervention by 20-fold 1
- In pediatric patients, use PECARN criteria to guide imaging decisions, with immediate CT for high-risk features including altered mental status, GCS ≤14, or palpable skull fracture in infants 3
Risk Stratification Based on Fracture Type and Clinical Presentation
Basilar Skull Fractures
Patients with basilar skull fractures and GCS ≥13 without intracranial pathology on CT can be managed on a regular floor without intensive care monitoring. 4
- In a study of 259 patients with basilar skull fractures, those with GCS ≥13 and no intracranial pathology had only 1% complication rate and no neurologically-related mortality 4
- Prophylactic antibiotics are not recommended for basilar skull fractures, as the best prevention of infection is operative debridement when indicated, not routine antibiotic prophylaxis 5
- Obtain neurosurgical consultation in all cases of basilar skull fracture 4
Depressed Skull Fractures
Compound depressed skull fractures can be managed nonsurgically if specific criteria are met, avoiding unnecessary craniotomy in approximately 48% of cases. 6
Criteria for Nonsurgical Management 6:
- No exposed brain or cerebrospinal fluid leak
- No pneumocephalus related to the fracture
- No depressed bone fragments >1 cm below the inner table
- No gross wound contamination
- No significant intracranial hematoma
- No dural violation over the brain convexity
Nonsurgical Treatment Protocol 6:
- Wound irrigation and debridement
- Primary wound closure
- Intravenous antibiotics for 5-7 days
- Additional 2 days observation off antibiotics before discharge
- This approach has shown no infectious complications related to the central nervous system
Surgical Indications 6:
- Significant intracranial hematomas
- Dural violations over the convexity
- Depressed fragments >1 cm below inner table
- Exposed brain or CSF leak
- Surgical therapy consists of craniotomy with debridement, elevation of fragments, dural repair, and hematoma evacuation
Growing Skull Fractures (Pediatric)
Children aged ≤3 years with cephalohematoma, underlying brain damage, bone diastasis ≥4 mm on CT, or immediate post-injury seizures require MRI brain scanning and early surgical intervention to prevent neurological deficits. 7
- Growing skull fractures occur in approximately 1.6% of all skull fractures and are a rare but serious complication 8
- Early diagnosis within 30 days and surgical repair of dura and skull is associated with good outcomes 7
- Continued growth of skull fractures correlates closely with increasing neurological deficit in the majority of cases 8
Management Based on Associated Intracranial Injury
Patients with Intracranial Pathology
Any patient with skull fracture and intracranial pathology on CT requires neurosurgical consultation and admission to a monitored setting. 4, 9
- Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 9
- Ensure oxygen saturation >90% as hypoxemia is associated with increased mortality 9
- Consider mannitol for elevated intracranial pressure, which works by increasing osmotic pressure of plasma and extracellular space, inducing movement of intracellular water to reduce intracranial pressure 10
- Reverse any coagulopathy immediately if patient is anticoagulated 9
- Serial neurologic examinations are mandatory 2
Patients without Intracranial Pathology
Patients with isolated skull fractures and negative CT for intracranial injury can be safely discharged from the emergency department with appropriate instructions. 2
Discharge Requirements 2:
- Both written and verbal instructions to return immediately for memory problems, confusion, abnormal behavior, increased sleepiness, or loss of consciousness
- Instructions written at 6th-7th grade reading level with font ≥12 points
- Education about postconcussive symptoms including dizziness, nausea, vision problems, sensitivity to noise/light, depression, mood swings, anxiety, and sleep disturbances
- Do not recommend frequent waking or pupil assessment at home for patients with negative CT scans
Important Exceptions 2:
- Patients on anticoagulation therapy (warfarin, NOACs)
- Patients on antiplatelet therapy beyond aspirin
- Patients with bleeding disorders
- Patients with previous neurosurgical procedures
- These populations require individualized assessment and potentially admission despite negative CT
Special Populations
Elderly Patients (≥60 years)
- Age ≥60 years is an independent risk factor for intracranial injury and lowers the threshold for CT imaging 2
- Elderly patients with skull fractures and any focal neurological deficit require immediate neurosurgical consultation and monitored setting 9
Pediatric Patients
- For children <2 years: High-risk features include GCS 14, altered mental status, or any palpable skull fracture (4.4% risk of clinically important injury) 3
- For children ≥2 years: High-risk features include GCS 14, altered mental status, or signs of basilar skull fracture (4.3% risk of clinically important injury) 3
- Clinical observation in the ED before CT imaging is effective in reducing unnecessary radiation without increasing missed injuries 2