What are the signs of a skull fracture?

Signs of Skull Fracture

Physical examination findings suggestive of skull fracture include palpable skull fracture, signs of basilar skull fracture (Battle's sign, raccoon eyes, cerebrospinal fluid rhinorrhea or otorrhea, hemotympanum), and visible scalp deformities—these findings are highly specific (99%) and strongly predictive of intracranial injury requiring intervention. 1, 2

Clinical Signs by Fracture Location

Basilar Skull Fracture Signs

• Battle's sign: Retroauricular ecchymosis (bruising behind the ear) 3
• Raccoon eyes: Periorbital ecchymosis (bruising around both eyes) 3
• CSF rhinorrhea: Clear fluid draining from the nose 1, 3
• CSF otorrhea: Clear fluid draining from the ear 1, 3
• Hemotympanum: Blood behind the tympanic membrane 1
• Cranial nerve injuries: Particularly facial nerve palsy or hearing loss 3
• Conductive or sensorineural hearing loss in petrous bone fractures 3
• Dizziness and nausea from labyrinthine involvement 3

Vault (Calvarium) Fracture Signs

• Palpable skull fracture: Step-off or depression felt on examination (likelihood ratio 16, specificity 99%) 1, 2
• Visible scalp deformity or depression 4
• Scalp hematoma or swelling overlying fracture site 1
• Physical evidence of trauma above the clavicle 1

Associated Clinical Features That Increase Suspicion

High-Risk Historical Features

• Age >60-65 years (increases risk significantly) 1, 2
• Pedestrian struck by motor vehicle (LR 3.0-4.3, specificity 96-97%) 2
• Fall from height >1 meter 1
• High-velocity blunt trauma 3

Neurological Signs

• Glasgow Coma Scale score of 13 (LR 4.9, specificity 97%) 1, 2
• Any decline in GCS score (LR 3.4-16, specificity 91-99%) 2
• Altered mental status or failure to reach GCS 15 within 2 hours 1
• Focal neurological deficits including hemiplegia, facial palsy, or fixed gaze deviation 5
• Amnesia >30 minutes 1, 2

Systemic Signs

• Two or more episodes of vomiting (LR 3.6, specificity 92%) 1, 2
• Severe or persistent headache 1
• Seizure activity 1

Age-Specific Considerations

Pediatric Patients (<24 months)

• Any skull fracture in infants 0-11 months warrants skeletal survey to evaluate for non-accidental trauma 1
• Complex or "ping-pong" skull fractures are particularly concerning 1
• Linear, unilateral skull fractures in infants 7-11 months from reported high falls may be accidental 1
• Behavioral changes in toddlers who cannot report symptoms (increased irritability, excessive drowsiness, altered feeding) 4

Adults

• Elderly patients (>60-65 years) have higher risk of intracranial injury even with minor trauma 1, 2

Critical Pitfall to Avoid

Do not rely on skull radiographs for diagnosis—they have only 63% sensitivity for detecting skull fractures and cannot identify intracranial injuries such as hemorrhage, edema, or midline shift. 1 CT imaging is the appropriate diagnostic modality when skull fracture is suspected based on clinical examination, as it better detects both fractures and associated intracranial complications. 1

When Imaging Is Indicated

Obtain non-contrast head CT immediately if any of the following are present: 1, 4

• Physical signs of skull fracture (palpable fracture, basilar skull fracture signs)
• GCS score ≤14
• Any decline in GCS score
• Focal neurological deficits
• Two or more vomiting episodes
• Age >64-65 years with any head trauma mechanism

The presence of suspected open or depressed skull fracture, dural tear, significant mass effect, or gross contamination may require neurosurgical intervention, though timing can be individualized based on cerebral perfusion pressure management in select cases. 6, 5