fracture base of skull

see also:

• head injury in the adult patient
• paediatric head injury
• trauma

• skull fracture indicates substantial force was involved
• basilar skull fractures have a high incidence of intracranial haemorrhage
• the following assumes other injuries have been managed and a primary and secondary survey carries out, in particular, cervical spine injury should be actively considered, as up to 15% of patients with skull fracture sustain a Cx spine fracture as well.

• Battle sign:
  • retroauricular or mastoid bruising - usually occurs 1-3 days after injury
• Racoon eyes:
  • bilateral periorbital haematoma - usually occurs 1-3 days after injury
• haemotympanum:
  • blood behind the ear drum suggests fracture of petrous ridge of the temporal bone and tends to occur within hours of injury
• CSF leak:
  • dural tears may allow CSF to leak into the paranasal sinuses and then into the nose, or into the middle ear.
  • CSF leaks occur in up to 45% of basilar fractures with onset of up to several days post injury
  • these may manifest either by clear rhinorrhoea or clear otorrhoea
    • testing rhinorrhoea for glucose can give false positives and negatives and not clinically useful
      • nasal secretions and tears may have reducing substances giving false positives
      • hyperglycaemia may give false positive
      • meningitis may lower CSF glucose giving false negative
• subconjunctival haemorrhage without visible posterior border:
  • subconjunctival haemorrhage is a common condition, but in the setting of head trauma is suggestive of basilar fracture if the posterior border of the haemorrhage cannot be seen.

• extradural haematoma:
  • as the most common basilar fracture involves the temporal bone, and thus near the middle meningeal artery, extradural haemorrhage is a significant risk
• subdural haematoma:
  • a significant risk, particular if patients are on anticoagulants
• persistent CSF leak:
  • most resolve within 1 week without complication
  • those with persistent leak > 1 week should be given prophylactic antibiotics as per penetrating head trauma
• CNS infection:
  • meningitis risk from CSF leaks has been estimated at 3% in the 1st week and rises substantially in those with persistent CSF leak > 1 week
• cranial nerve palsy:
  • acute onset facial nerve palsy at time of injury indicates nerve transection
  • delayed onset nerve palsy suggests neuropraxia from compression or contusion
• traumatic carotid cavernous fistula (TCCF):
  • a rare complication occurring in ~4% of patients with basilar fractures
• carotid artery thrombosis or dissection:
  • a rare complication

• CT brain to exclude intracranial haemorrhage if:
  • evidence or suspicion of basilar skull fracture, or,
  • patient on anticoagulants with a head injury, or,
  • other trauma indicators for performing CT brain such as persistent vomiting, reduced GCS, intoxication, etc.
• patients for active Rx who are at increased risk of bleeding (eg. on anticoagulants such as warfarin or clopidogrel):
  • reverse warfarin
  • should be admitted and observed for at least 24 hours with hourly neuro obs at least for the first 6 hours.
  • repeat CT brain if subsequent deterioration, as there is a risk of delayed subdural haematoma collecting.
• patients with CSF leak > 1 week should be given prophylactic antibiotics¹⁾