What are the signs of a basilar skull fracture in a pediatric patient and how should it be managed?

Basilar Skull Fracture: Clinical Signs and Management in Pediatric Patients

Clinical Signs of Basilar Skull Fracture

The classic signs of basilar skull fracture include hemotympanum (blood behind the tympanic membrane), bleeding from the ear canal, periorbital ecchymosis ("raccoon eyes"), and postauricular ecchymosis (Battle's sign), though these signs may be delayed or absent in the acute setting. 1

Key Physical Examination Findings:

• Hemotympanum - blood visible behind the eardrum 1
• Otorrhea - bleeding or cerebrospinal fluid (CSF) leak from the ear canal 1, 2
• Periorbital ecchymosis - bruising around the eyes ("raccoon eyes") 1
• Postauricular ecchymosis - bruising behind the ear (Battle's sign) 1
• Rhinorrhea - CSF leak from the nose 2

Critical Clinical Context:

• Physical examination signs of basilar skull fracture are present in only 28.7% of children who actually have basilar skull fracture on CT imaging 3
• Conversely, only 39.1% of children with basilar skull fracture confirmed on CT have the classic physical examination signs 3
• This poor correlation means CT imaging is mandatory to adequately stratify risk, as physical signs alone are insufficient 3

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Risk Stratification

Any child with signs of basilar skull fracture—regardless of age or Glasgow Coma Scale (GCS) score—is automatically classified as HIGH RISK, with approximately 4.3-4.4% risk of clinically important traumatic brain injury. 4, 5, 1

PECARN High-Risk Criteria:

For children ≥2 years old: 6

• GCS = 14 or other signs of altered mental status, OR
• Signs of basilar skull fracture

For children <2 years old: 6

• GCS = 14 or other signs of altered mental status, OR
• Signs of basilar skull fracture, OR
• Palpable skull fracture

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Immediate Management

Imaging Protocol:

Non-contrast CT head is mandatory for any child with suspected basilar skull fracture signs—this is non-negotiable. 1, 3

• CT without IV contrast is the initial imaging modality of choice 4
• Multiplanar and 3D-reconstructed images should ideally be performed to increase sensitivity for fractures and small hemorrhages 6, 4
• Use dedicated pediatric CT protocols tailored to patient size to minimize radiation exposure 4, 5

Do NOT obtain skull radiographs instead of CT—they miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 4, 5, 1

Additional Vascular Imaging:

Strongly consider CT angiography (CTA) in addition to non-contrast CT, as basilar skull fractures carry high risk for traumatic arterial dissection, especially when the fracture extends through a vascular canal. 4, 1

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Disposition and Monitoring

Admission Criteria:

All children with basilar skull fracture signs require hospital admission for close neurological observation with serial examinations, even if initial GCS is 15. 1

Exception - Isolated Basilar Skull Fracture:

The evidence shows that children with isolated basilar skull fracture (confirmed on CT with no other intracranial injuries) have excellent outcomes: 3

• Zero acute adverse outcomes (0%; 95% CI 0% to 1.4%) in one large study of 256 patients 3
• These patients are candidates for ED discharge IF: 7, 3
  • Neurologically normal after CT and observation
  • Tolerating oral fluids
  • No evidence of CSF leak
  • Evaluated by appropriate subspecialists before discharge
  • Reliable follow-up available

Complications to Monitor:

CSF leak occurs in approximately 32% of pediatric patients with basilar skull fractures (otorrhea being most common), requiring subspecialty consultation. 2

Other potential complications include: 7, 2

• Facial nerve abnormality (1.2% in one series) 7
• Central diabetes insipidus 2
• Vascular injury/dissection 1
• Meningitis (though rare in modern series) 7

Mortality Risk:

Basilar skull fractures are independent predictors of mortality in pediatric severe traumatic brain injury (OR 6.87), particularly when associated with subarachnoid hemorrhage, contusion, herniation, or cerebral edema. 2

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Special Considerations

Non-Accidental Trauma:

Maintain a low threshold for considering non-accidental trauma in infants with basilar skull fracture, especially with inconsistent history or unexplained mechanism. 5, 1

Temporal Bone Involvement:

The squamous temporal bone is the most frequently fractured location in basilar skull fractures (occurring in approximately two-thirds of cases), and temporal bone fractures are strongly associated with CSF otorrhea. 2

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Common Pitfalls to Avoid

• Do not rely on physical examination signs alone to rule out basilar skull fracture—they are present in less than one-third of confirmed cases 3
• Do not discharge children with basilar skull fracture signs without CT imaging—physical signs automatically place them in high-risk category requiring imaging 4, 1
• Do not use skull radiographs as a substitute for CT—they are inadequate and miss half of intracranial injuries 4, 5, 1
• Do not forget to evaluate for CSF leak before discharge, as it occurs in nearly one-third of cases and requires subspecialty management 2
• Do not delay imaging for prolonged observation when basilar skull fracture signs are present—this represents a clear indication for immediate CT 4