Skull fractures

Last updated: August 3, 2023

Summarytoggle arrow icon

Skull fractures most typically occur as a result of blunt force trauma from contact sports, motor vehicle collisions, or falls. They are classified by anatomical location as either cranial vault fractures or basilar skull fractures. Cranial vault fractures involve one or more of the cranial vault bones, may be either open fractures or closed fractures, and are classified as linear skull fractures or depressed skull fractures. Basilar skull fractures involve one or more of the skull base bones and are classified as anterior, middle, or posterior cranial fossa fractures. Clinical features vary depending on bone involvement but may include lacerations, contusions, and hematoma of the scalp; palpable deformities; mobile bone fragments; liquorrhea; Battle sign; raccoon eyes; and signs of traumatic brain injury. Initial management of skull fractures focuses on identifying and addressing life-threatening injuries. Complications of skull fractures include CSF leaks (which increase the risk for meningitis), cranial nerve disorders (due to compression or transection), and epidural hematomas. Expectant management may be sufficient for simple fractures but neurosurgery may be necessary for unstable fractures and fractures with associated complications. Open head injuries can occur when skull fractures are associated with rupture of the dura mater, which can increase the risk of CNS infection.

See also “Facial fractures,” and “Orbital floor fractures” in “Traumatic eye injuries.”

Managementtoggle arrow icon

Initial management [1]

Follow the ATLS algorithm for any patient with a potentially significant head injury, and maintain a low threshold for early specialist consultation (e.g., neurosurgery).

Assume patients with high-impact head trauma have a cervical spine injury until it has been ruled out.

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

Supportive care [1]

Definitive management [1]

See also “Management of moderate and severe TBI.”

Determine appropriate patient disposition based on the type of fracture and the presence of TBI or other complications.

Cranial vault fracturetoggle arrow icon

Definitions [2][3]


See “Etiology of TBI.”

Clinical features [1]

Most commonly involves the frontal and parietal bones

Use caution when examining head injuries to avoid pushing potential depressed skull fractures further into the cranium. [1]

Diagnostics [1][4]

See also “Diagnostics in TBI.”

  • CT head without IV contrast (preferred modality)
    • Evaluate for fracture lines.
    • Assess for intracranial injury.
  • X-ray skull: may be used if CT is not available

Linear skull fracture [1][2]

Depressed skull fracture [1][2]

Open depressed skull fractures are often considered open head injuries because of the high prevalence of associated dural tears. Antibiotic prophylaxis is recommended. [1][3]

Basilar skull fracturestoggle arrow icon

Definition [2]


See also “Etiology of TBI.”

  • Caused by significant high-energy trauma to the skull
  • Most commonly results from motor vehicle, motorcycle, or pedestrian-motor vehicle collisions
  • Other causes
    • Violent altercations
    • Falls
    • Firearms

Classification [2]

Clinical features of basilar skull fractures [5][6]

CSF otorrhea, hemotympanum, vertigo, hearing loss, and/or facial nerve palsy suggest fracture of the petrous portion of the temporal bone. [2][5]

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

Diagnostics [1][4][6]

See also “Diagnostics in TBI.”

Basilar skull fractures can injure the internal carotid artery. Obtain urgent CT angiography head in patients with signs of carotid-cavernous fistula or stroke. [4]

Management [1][8]

Initial management

Definitive management

Avoid nasogastric tubes and nasotracheal intubation in patients with a suspected ethmoid bone fracture, as they may cause direct intracranial injury.


  • Consult neurosurgery.
  • Admit all patients for observation.



Other complications

Temporal bone fracturestoggle arrow icon



Clinical features

Clinical features of petrous bone fractures by classification [12][13][14]
Longitudinal fracture Transverse fracture
  • Frontal or occipital force
Clinical features
Otoscopic findings

Diagnostics [12][13]

See also “Diagnostics” in “Basilar skull fractures.”

Treatment [13]


Perilymphatic fistula [15]

Other complications

Open head injuriestoggle arrow icon


Open head injury and open skull fracture can occur with the same skull fracture if there is disruption of the underlying dura AND of the overlying galea and skin.

Clinical features


CNS infection prophylaxis for open head injury [1][5]

Additional management

Referencestoggle arrow icon

  1. Diaz RC, et al. Treatment of Temporal Bone Fractures. J Neurol Surg B Skull Base. 2016; 77 (5): p.419–429.doi: 10.1055/s-0036-1584197 . | Open in Read by QxMD
  2. Patel A, Groppo E. Management of Temporal Bone Trauma. Craniomaxillofacial Trauma & Reconstruction. 2010; 3 (2): p.105-113.doi: 10.1055/s-0030-1254383 . | Open in Read by QxMD
  3. Önerci TM. Temporal Bone Fractures. Springer Berlin Heidelberg ; 2009: p. 50-51
  4. Sarna B, Abouzari M, Merna C, Jamshidi S, Saber T, Djalilian HR. Perilymphatic Fistula: A Review of Classification, Etiology, Diagnosis, and Treatment.. Frontiers in neurology. 2020; 11: p.1046.doi: 10.3389/fneur.2020.01046 . | Open in Read by QxMD
  5. Di Ieva A, Audigé L, Kellman RM, et al. The Comprehensive AOCMF Classification: Skull Base and Cranial Vault Fractures — Level 2 and 3 Tutorial. Craniomaxillofacial Trauma & Reconstruction. 2014; 7 (1_suppl): p.103-113.doi: 10.1055/s-0034-1389563 . | Open in Read by QxMD
  6. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy D, Meckler GD, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw Hill Professional ; 2019
  7. Shen P, Dublin A, Bobinski M. Basic Imaging of Skull Base Trauma. Journal of Neurological Surgery Part B: Skull Base. 2016; 77 (05): p.381-387.doi: 10.1055/s-0036-1583540 . | Open in Read by QxMD
  8. Watanabe K, Kida W. Images in clinical medicine: Battle's sign. N Engl J Med. 2012; 367 (12): p.1135.doi: 10.1056/NEJMicm1100820 . | Open in Read by QxMD
  9. Shetty VS, Reis MN, et al. ACR Appropriateness Criteria Head Trauma. Journal of the American College of Radiology. 2015.
  10. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  11. Lin DT, et al. Surgical treatment of traumatic injuries of the cranial base. Otolaryngol Clin North Am .. 2013.doi: 10.1016/j.otc.2013.06.008 . | Open in Read by QxMD
  12. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews. 2015; 4: p.CD004884.doi: 10.1002/14651858.cd004884.pub4 . | Open in Read by QxMD
  13. Le C, Strong E, Luu Q. Management of Anterior Skull Base Cerebrospinal Fluid Leaks. Journal of Neurological Surgery Part B: Skull Base. 2016; 77 (05): p.404-411.doi: 10.1055/s-0036-1584229 . | Open in Read by QxMD
  14. Sunder R, et al. Basal skull fracture and the halo sign. CMAJ JAMC. 2013.
  15. Bullock MR, Chesnut R, Ghajar J, et al. Surgical Management of Depressed Cranial Fractures. Neurosurgery. 2006; 58 (suppl_3): p.S2-56-S2-60.doi: 10.1227/01.neu.0000210367.14043.0e . | Open in Read by QxMD
  16. Harmon LA, Haase DJ, Kufera JA, et al. Infection after penetrating brain injury. Journal of Trauma and Acute Care Surgery. 2019; 87 (1): p.61-67.doi: 10.1097/ta.0000000000002327 . | Open in Read by QxMD
  17. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016; 80 (1): p.6-15.doi: 10.1227/neu.0000000000001432 . | Open in Read by QxMD
  18. Rosenfeld JV, Bell RS, Armonda R. Current Concepts in Penetrating and Blast Injury to the Central Nervous System. World J Surg. 2014; 39 (6): p.1352-1362.doi: 10.1007/s00268-014-2874-7 . | Open in Read by QxMD
  19. Le Roux P, Menon DK, Citerio G, et al. Consensus Summary Statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care. Neurocrit Care. 2014; 21 (S2): p.1-26.doi: 10.1007/s12028-014-0041-5 . | Open in Read by QxMD

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