Skull X-Ray Views for Fracture Diagnosis
Skull radiographs should not be used for diagnosing skull fractures in the evaluation of head trauma, as CT head with bone algorithm reconstructions provides superior sensitivity for detecting fractures and is the only modality that can identify clinically significant intracranial injuries. 1
Primary Recommendation: Avoid Skull Radiographs
The CDC explicitly recommends against using skull radiographs for diagnosing pediatric mild traumatic brain injury (mTBI) or screening for intracranial complications (high-level recommendation). 1 This recommendation extends to adult populations based on multiple professional society guidelines. 1
Why Skull X-Rays Are Inadequate
Poor sensitivity: Skull radiographs have only 38-63% sensitivity for detecting skull fractures, missing a substantial proportion of fractures that are visible on CT. 1, 2
Cannot detect intracranial injury: Radiographs cannot visualize hemorrhage, midline shift, cerebral edema, or other intracranial complications that determine patient outcomes and need for neurosurgical intervention. 1
Misleading negative results: Negative skull films may falsely reassure clinicians despite the presence of significant intracranial pathology—70% of patients with intracranial lesions had no fracture visible on radiographs in one study. 1
Technical limitations: Linear fractures running parallel to the x-ray beam or with oblique cross-sections are frequently missed on standard anteroposterior (AP) and lateral views. 3, 4
Current Standard of Care: CT Head
CT head without contrast using bone algorithm reconstructions is the first-line imaging modality for suspected skull fracture, providing superior detection of both fractures and associated intracranial injuries. 1
CT Advantages Over Radiography
Superior fracture detection: CT bone windows detect skull fractures with much higher sensitivity than plain films, including subtle non-displaced fractures. 1
Multiplanar capability: Multiplanar reformations increase sensitivity for hemorrhage detection and better characterize fracture patterns. 1
Simultaneous brain evaluation: CT identifies clinically significant intracranial complications (hemorrhage, edema, mass effect) that determine management and prognosis. 1
Comprehensive assessment: CT can be reconstructed to evaluate maxillofacial and skull base injuries from the same acquisition. 1
Historical Context: When Skull X-Rays Were Used
If skull radiographs were to be obtained (which is not recommended in current practice), the traditional trauma series included:
- Standard views: AP and lateral skull views 5
- Towne view: Essential for detecting basilar skull fractures, particularly in the occipital bone—59% of basilar fractures were visible only on Towne view in one series, with 19% of these being normal on AP/lateral films. 5
However, even with comprehensive radiographic views including Towne projections, the sensitivity remains inadequate compared to CT. 1, 5
Clinical Decision Algorithm
For any patient with head trauma where imaging is clinically indicated:
Do not obtain skull radiographs 1
Proceed directly to non-contrast CT head with bone algorithm reconstructions if imaging is warranted based on validated clinical decision rules 1
Use established criteria (e.g., Canadian CT Head Rule, New Orleans Criteria for adults; PECARN rules for children) to determine which patients require CT imaging 1
Common Pitfalls to Avoid
Do not use skull radiographs as a "screening test" before deciding on CT—this delays definitive diagnosis and provides no useful clinical information. 1
Do not be falsely reassured by negative skull films—the absence of fracture on radiography does not exclude intracranial injury requiring intervention. 1, 2
Avoid radiation exposure from skull films when CT will ultimately be needed anyway—skull radiographs use ionizing radiation without providing the diagnostic information necessary for clinical decision-making. 1