Skull Fracture Diagnosis and Management

Clinical Signs and Symptoms

The American College of Emergency Physicians suggests that physical examination findings suggestive of skull fracture, such as palpable skull fracture, signs of basilar skull fracture, and visible scalp deformities, are highly specific (99%) and strongly predictive of intracranial injury requiring intervention 1
The presence of hemotympanum, or blood behind the tympanic membrane, is a sign of basilar skull fracture 1
A palpable skull fracture, or step-off, felt on examination has a likelihood ratio of 16 and specificity of 99% for skull fracture 1
Visible scalp deformity or depression is a sign of vault fracture 2
Scalp hematoma or swelling overlying the fracture site is a sign of trauma 3
Physical evidence of trauma above the clavicle increases suspicion of skull fracture 1

The American College of Emergency Physicians recommends considering age >60-65 years as a high-risk factor for intracranial injury, as it increases risk significantly 1
Fall from height >1 meter increases suspicion of skull fracture 1
Altered mental status or failure to reach Glasgow Coma Scale (GCS) score of 15 within 2 hours is a concerning sign 1

A GCS score of 13 has a likelihood ratio of 4.9 and specificity of 97% for intracranial injury 1
Any decline in GCS score is a concerning sign, with a likelihood ratio of 3.4-16 and specificity of 91-99% 1
Amnesia >30 minutes is a sign of potential intracranial injury 1

Two or more episodes of vomiting has a likelihood ratio of 3.6 and specificity of 92% for intracranial injury 1
Severe or persistent headache is a concerning sign 1
Seizure activity is a sign of potential intracranial injury 1

The American Academy of Pediatrics recommends that any skull fracture in infants 0-11 months warrants skeletal survey to evaluate for non-accidental trauma 4
Complex or "ping-pong" skull fractures are particularly concerning in pediatric patients 4
Behavioral changes, such as increased irritability, excessive drowsiness, or altered feeding, are concerning signs in toddlers who cannot report symptoms 2

The American College of Radiology recommends that CT imaging is the appropriate diagnostic modality when skull fracture is suspected based on clinical examination, as it better detects both fractures and associated intracranial complications 1, 5
Non-contrast head CT should be obtained immediately if there are physical signs of skull fracture, GCS score ≤14, any decline in GCS score, focal neurological deficits, two or more vomiting episodes, or age >64-65 years with any head trauma mechanism 1, 2

Non‑contrast head CT is the preferred initial imaging modality because it simultaneously detects skull fractures and associated intracranial complications (e.g., hemorrhage, edema, midline shift), which plain skull radiographs cannot visualize. [6][7]8
Skull radiographs have limited diagnostic performance, with only ≈ 63 % sensitivity for identifying skull fractures and no capability to assess intracranial injury. [6][7]8

Acute magnetic resonance imaging should be avoided in the initial assessment of a child with a palpable skull depression, as it requires longer acquisition times, often necessitates sedation, and is not endorsed for routine emergency evaluation of suspected skull fracture. [6][7]8

Head CT can reliably reveal brain edema or contusion associated with skull trauma, providing essential information for risk stratification and management decisions. 6

Detection of midline shift on head CT is feasible and serves as a critical indicator of significant intracranial mass effect requiring neurosurgical consultation. 6