One of the most feared injuries is that of the fractured skull. A fractured skull can be minor and self-healing; it can also be severe with internal bleeding into the brain or damage to brain tissue itself. In this summary, we will look at the features of a fractured skull, what causes it and how to treat it.
What is a Fractured Skull?
The skull is not just one bone but is the sum of several bones, including the parietal bone, the temporal bone, the occipital bone and the frontal bone, among others. When the skull is fractured, there is a break in one or more of the bones.
Fractures can be linear—just a line of broken bone that extends from one part of the skull to the other. It can also be comminuted, with multiple pieces of bone involved, some of them free floating on the brain. A depressed skull fracture involves a free floating piece of bone that has been pushed into the brain tissue, resulting in damage to the brain at that site. A compound fracture is one that is very severe, with splintering of bone and many pieces with a high risk of brain trauma.
Skull fractures are not terribly common. There are about 42.409 skull fractures seen in hospitals per year. This represents 1 in 6,413 people or about 0.02 percent of the population. It would be rare to have a skull fracture and not need some kind of medical attention.
The biggest risk of a skull fracture is not the fracture itself but the proximity of the skull to the brain. Skull fractures are sometimes associated with a brain injury that can occur because of the fracture or incidental to the fracture. It’s the brain injury that causes all the morbidity and mortality of a skull fracture.
Causes of a Fractured Skull
Fractured skulls occur under a variety of conditions. They are commonly seen in motor vehicle and motorcycle accidents, in which the passenger or driver’s head strikes the roof of the car or hits the dashboard, or the victim is ejected and strikes the windshield and the ground. Other skull fractures happen when a person falls from a great distance or is involved in a sporting injury. Children can suffer a fracture during playground play.
Fractured skulls can also unfortunately happen in situations of child abuse and in altercations, especially those involving objects like bats and metal pipes. The skull can also be fractured as part of a penetrating injury such as a gunshot injury. In fact, any kind of head injury or head trauma can cause a skull fracture as well.
Symptoms of a Skull Fracture
A skull fracture is almost always painful so the individual will have some kind of headache that can be localized to the site of the fracture or generalized. There may be local swelling and bruising at the site of the fracture. In open fractures, there is a laceration of the scalp or forehead that communicates with the fracture. This puts the person at risk for infection in the bone or, because the skull houses the brain, brain infections like meningitis or encephalitis.
In a skull fracture, there can be disruption of the dura covering the brain and containing the cerebrospinal fluid. When the dura is disrupted, the CSF leaks out, often leaking through the ears or nose. The finding of CSF dripping from the ears or nose is a good sign that the skull has been fractured somewhere.
Many skull fractures result in bleeding inside the skull itself. A person can have an epidural hematoma or a subdural hematoma along with their skull fractures. These are dangerous side effects of skull fractures and often need to be evacuated so they don’t build up pressure in the brain and cause further brain damage.
Some skull fractures do not cause hematomas but are depressed and cause trauma directly to the brain. Patients can have confusion, loss of consciousness, memory loss, or a focal neurological deficit, such as paralysis of an arm, leg or both. Such complications can be temporary and due to brain swelling or bruising; they can also represent permanent brain injury with permanent deficits.
Other symptoms of a skull fracture include the following:
- Bleeding or bruising around the eyes, behind the ear (Battle sign), from the wound, ears or nose
- Changes in the size of the pupils
- Balance problems
- Fatigue or drowsiness
- Visual changes
- Stiff neck
- Slurred speech
If any of the above symptoms and signs are present, a fractured skull could be the cause of the problem and immediate medical attention is required in order to minimize the damage to the brain inside and beneath the skull fracture.
Risk Factors for a Fractured Skull
The key risk factors for a skull fracture include being male, engaging in high risk behaviors like riding a motorcycle, driving recklessly, engaging in fights and playing sports. Other risk factors include being a child and being involved in a fall. Those who ride motorcycles and bicycles should wear a helmet at all times because they can be thrown over the handlebars resulting in head injuries, cervical spine injuries, and skull fractures. Children from high risk homes are at risk for violence against them. Their skulls are fragile and can easily fracture.
Diagnosis of a Skull Fracture
Before any test for skull fracture is done, the doctor must do a complete physical and neurological examination in order to look for signs and symptoms of a skull fracture. The head is examined for areas of swelling, tenderness or bruising. The ears and nose are examined to see if blood or cerebrospinal fluid are coming out. Bruising around the eyes can be “Raccoon’s Eyes”, a sign of skull fracture, and bruising behind the ears can be a Battle Sign—evidence of a basilar skull fracture.
The doctor assesses the level of consciousness, looks for the presence of seizures or pupillary differences, and assesses the balancing abilities and level of confusion in the patient. Sometimes a Glasgow Coma Scale is done. This is an assessment of the level of consciousness of the patient and predicts outcome of the patient’s mental status later.
The Glasgow Coma scale goes like this:
- Eye opening response: Open with blinking—4 points
- Verbal Response: Oriented—5 points
- Motor Response: Obeys commands—6 points
Opens to verbal command—3 points
Opens to pain not applied to the face—2 points
No eye opening—1 point
Confused but can answer questions—4 points
Inappropriate responses but with words discernible—3 points
Incomprensible speech—2 points
No speech—1 point
Purposeful movement to a painful stimulus—5 points
Withdraws from pain—4 points
Abnormal spastic flexion—3 points
Extensor response (decerebrate posture)—2 points
No movement—1 point
A score of between 3 and 8 points indicates the patient is in a coma and has a poorer prognosis.
When the index of suspicion of is high enough, x-ray films can be done of the skull using the anterior-posterior and lateral views. This can show areas of linearity or compound fractures of the skull or can point to a foreign body, such as a bullet. X-rays were once the only way to assess skull fractures. Now CT scans are used to assess areas of skull fractures along with areas of brain damage or bleeding inside the brain from the skull fracture. If bleeding is found, its location and size can be identified and the individual can have a burr hole placed in the skull in order to drain the brain from any hematoma found. The CT scan is especially good when it comes to looking at bones and finding areas of bleeding or bruising on the brain.
Treatment of a Skull Fracture
The treatment of a skull fracture depends on the type and severity of the fracture. Fortunately, many fractures of the skull need no treatment because the bones splint themselves, the fracture is not displaced, and the bone will heal itself over time. Most of the treatment of skull fractures involves pain control, the promotion of healing and the prevention of any complications. The biggest complication to be monitored for is traumatic brain injury, which can happen with any type of skull fracture.
In a linear skull fracture, treatment is rarely necessary. It shows up as a crack in the skull bone and is rarely out of place. Pain control is the best possible treatment if there is no evidence of bleeding behind the fracture. The patient can be sent home and is cautioned against doing anything that might make the head trauma worse. If there are no complications, the patient will generally heal without difficulty.
In a basilar skull fracture, the outcome can be more complicated. The fracture sometimes extends into the sinus cavities, causing sinus complications and can rip a whole in the dura which holds the cerebrospinal fluid. If this happens, the cerebrospinal fluid leaks out and shows up as pink or red-tinged fluid coming from the ears or nose. This can become a portal for infection into the brain. Sometimes antibiotics are used to prevent a brain or meningeal infection from a tear in the dura.
The CSF can build up beneath the skin around the eyes or behind the ears, leading to a bruised look that is specific to basilar skull fractures but can mean there is a greater injury in the brain than once thought. Most dura injuries seal themselves within 48 hours. Patients are hospitalized for at least part of that time. If the drainage does not stop, a drainage tube is placed in the skull itself which reduces the pressure in the brain and helps healing.
If the brain is broken up into many pieces, doctors call this a “comminuted fracture”, although it is sometimes called a multi-fragmentary or radial fracture of the skull. If the bones have stayed in proper alignment and no fragment is depressed, it is treated much like a linear fracture and is not treated surgically. They generally heal without intervention. Again, the patient is told to avoid any activity that could further injure the skull or the brain.
If, on the other hand, the bones are out of alignment, surgery is necessary to remove fragments or use plates to hold them together. If the dura has not been penetrated and there is no brain damage, the outlook is good. If the dura is punctured, infection can happen. Fragments that impact the brain can cause brain damage.
In a depressed skull fracture, one or more fragment is depressed and is pushing on the brain. The treatment depends on how deep the depression is. It also depends on whether or not there is an open wound overlying the fracture. If the depression is less than the thickness of the skull and the fracture is closed without overlying laceration, the wound generally heals well.
If the depression is deeper and if it has an open wound, there is often a lot of brain damage and it is necessary to do surgery to remove fragments pressing on the brain and to treat areas of bleeding on the brain. In many cases, depressed skull fractures lead to mild, moderate or severe brain damage and permanent disability.
Complications of a Skull Fracture
Many skull fractures heal without intervention and without any brain injury or disability. These usually are the linear skull fractures or comminuted fractures that do not have any bones out of place.
If a fracture injures the dura and cerebrospinal fluid spills out, bacteria can get in and cause meningitis or encephalitis. These can cause permanent disability and require antibiotics to get better.
The biggest complication of a skull fracture happens when there is bleeding inside the skull fracture or when fragments are depressed and piercing the brain. This is where brain damage occurs along with permanent disability from portions of the brain that do not regenerate after an injury.
If you or a loved one has suffered a fractured skull as a result of someone else's negligence and would like to discuss your legal options with an experienced Sacramento Personal Injury Attorney, contact us online or call us at 916-921-6400 or toll-free at 800-404-5400 to set up a FREE consultation.