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Skull fractures

Last updated: May 18, 2021

Summarytoggle arrow icon

Skull bone fractures most typically occur due to blunt force trauma from contact sports, motor vehicle collisions, or falls. Skull fractures are classified according to the anatomic location of the fracture as basilar skull fractures, cranial vault fractures, mandibular fractures, and midfacial fractures. Fractures of the skull base are classified according to the affected region (anterior, middle, posterior cranial fossae). Cranial vault fractures may involve the frontal, parietal, temporal, sphenoid, and occipital bones. Midfacial bone fractures and basilar skull fractures can be simple (i.e., involving a single bone, e.g., nasal bone fractures, temporal bone fractures, zygomatic arch fractures) or complex (i.e., involving more than one bone, e.g., Le Fort fractures of the midfacial bones or zygomaticomaxillary complex fractures). All skull fractures can be subclassified further based on the number of fracture lines (simple or comminuted fractures), the degree of displacement (nondisplaced or depressed fractures), and the involvement of soft tissue (open or closed fractures). Clinical features vary depending on which bones are involved but usually include facial pain, bruising, palpable step-off(s), and mobile bone fragments. Initial management of skull fractures focuses on identifying and addressing life-threatening injuries. Watchful waiting may be sufficient for simple fractures, but neurosurgery may become necessary in unstable fractures and such complicated by CSF leaks or cranial nerve lesions. Complications of skull fractures include CSF leaks (with an increased risk for meningitis), cranial nerve disorders (due to compression or transection), epidural hematomas, and facial disfiguration.

For details regarding orbital floor fractures, please see the article “Traumatic eye injuries.”

Classification by fracture type

Classification by location

Clinical features [1]

Clinical features depend on the type of skull fracture. Common signs and symptoms of skull fractures are listed below. See the individual sections below for details.

Definition

Epidemiology

Etiology

  • Sports-related injuries are the most common cause.
  • Other causes of blunt trauma to the face include violent altercations (punches, elbowing) and falls. [3]
  • See the column on “Type of fracture” in the table on Le Fort fractures below for details regarding the mechanism of injury.

Classification and clinical features

  • Facial contusions, local swelling, and tenderness
  • Facial asymmetry and midface instability of varying degree
  • Palpable gap along the surface of the bone
  • Isolated nasal bone fractures and zygomatic fractures are discussed separately.
Le Fort classification of midfacial fractures [3][4]

Classification

Type of fracture Fracture line

Distinguishing features

Le Fort I
  • Horizontal maxillary fracture due to a high-energy impact against the alveolar ridge of the maxilla in a downward direction.
Le Fort II
  • Pyramidal maxillary fracture due to a high-energy impact against the mid and/or lower maxilla.
  • Runs from the nasal bridge (with or without involvement of the nasofrontal suture) via the frontomaxillary suture through the lacrimal bone to the inferior orbital floor
  • Passes inferior to the zygomatic bone through the lateral wall of the maxillary sinus and extends through the pterygomaxillary fissure and the pterygoid plates
  • Involvement of the infraorbital foramen is possible
Le Fort III
  • Transverse maxillary fracture due to a high-energy impact to the upper maxilla and nasal bridge.
  • Runs from the nasofrontal suture or the frontomaxillary suture posteriorly through the medial orbital wall, ethmoid air cells, pterygoid process, lateral and posterior orbital walls, and zygomatic arch

Diagnostics

Treatment

Epidemiology

  • Most common type of midfacial bone fracture [5]

Etiology

  • Blunt force trauma to the nose or midface
  • Often during sports or physical altercations

Clinical features

Diagnostics [6]

  • External and internal examination of the nose
  • Assess for concomitant orbital or midface injuries.
  • Cranial CT: modality of choice to evaluate severe nasal trauma or midfacial trauma

Treatment [6]

Complications

  • Nasal septal hematoma
    • Etiology: Nasal trauma results in hematoma formation between the cartilage and perichondrium.
    • Clinical features
      • Complete displacement of the nasal lumen with (double-sided) obstruction of nasal breathing shortly after injury
      • Absence of overt bleeding because the nasal mucosa remains intact
      • Possibly, changes in nasal shape
    • Diagnostics: rhinoscopy may show firm elastic, balloon-like protrusion of the mucous membrane
    • Treatment: immediate surgical drainage with subsequent tamponade to prevent further bleeding
  • Nasal septal perforation secondary to nasal septal hematoma
  • Saddle nose deformity
  • Deviated nasal septum
  • Nasal ventilation problems and snoring

Definitions [7]

Epidemiology

  • Second most common type of midfacial bone fracture [7]

Etiology

  • Sports-related injuries (e.g., direct impact with sporting equipment or players)
  • Physical altercations (e.g., punch or elbow impact with the malar eminence)

Clinical features

Diagnostics

  • Physical exam: Evaluate zygomatic symmetry and stability, palpable gaps along the surface of the bone, bone crepitus.
  • Cranial CT (modality of choice)
    • Evaluate the type and number of fracture lines, displacement of bone fragments and/or rotation, and the contour of the orbital boundaries.
    • Assess the orbital roof and orbital floor.
  • Ophthalmic examination: Evaluate visual acuity and ocular movement to rule out extraocular muscle entrapment.

Treatment

Definition

Etiology

Classification and clinical features

Classification of basilar skull fractures [8]

Type of basilar skull fracture Distinguishing clinical features
Anterior cranial fossa fracture (70%)
Middle cranial fossa fracture (25%)
Posterior cranial fossa fracture (5%)

Raccoon eyes, Battle sign, and CSF leakage are highly indicative of basilar skull fractures.

Neurological impairment, repeated vomiting, and seizures indicate potentially severe cerebral trauma or intracranial hemorrhage.

Diagnostics

Treatment

Nasogastric tubes and nasotracheal intubation are absolute contraindications in the setting of basilar skull fractures due to the risk of intracranial tube placement.

Complications

Definition

Etiology

  • Very high-energy blunt trauma to the temporal bone (often in association with polytrauma)
  • Most commonly occurs in motor vehicle collisions or other traffic-related injuries (e.g., bicycle vs. pedestrian collisions).

Classification and clinical features

Classification of temporal bone fractures
Impact Clinical features Otoscopic findings
Longitudinal fracture
Transverse fracture
  • Frontal or occipital force

Diagnostics

Treatment

Complications

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