Fractured Skull Injury
One of the most feared injuries is that of the fractured skull. In some cases, the damage is minimal and self-healing; in others, it can lead to internal bleeding or damage to the brain tissue. 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 you suffer from a skull fracture, there is a break in one or more of the bones.
Fractures can be linear—just a single fracture line 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 might even be free-floating in 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 skull fracture is a very severe one, with a splintering of the bone and many pieces with a high risk of brain trauma.
There are several different types of fractured skulls. They all have different mechanisms, treatment patterns, potential complications, and prognoses. It is essential to diagnose the correct type of fractured skull so that the injury can be adequately treated. The types of skull fractures include:
- Linear Skull Fractures: This is the most common type of skull fracture. There is typically a single fracture line on the surface of the skull. Even though the skull has been fractured, there is no shift in the position of the bone, and the pieces of the skull are still in the proper location. Because the bones are not shifting, the brain is typically unharmed. Linear skull fractures usually occur through a direct blow to the skull, such as in a fall injury. While some linear skull fractures can be severe, most individuals make a full recovery after a brief observation period in the hospital. Like other bone fractures, linear skull fractures heal gradually over a period of weeks to months.
- Depressed Skull Fractures: In a depressed skull fracture, part of the skull is actually pushed into the underlying brain tissue. This type of skull fracture often follows a motor vehicle accident or a physical assault. A tremendous force impacts the surface of the skull, splintering it and sending bone fragments into the brain. In some cases, there might even be a visible, bleeding cut along the surface of the scalp where the impact took place. In severe injuries, brain tissue might also be visible. Because a portion of the skull is actually pressed into the brain tissue, there is a high incidence of complications. Damage to the brain tissue underneath the skull could lead to the development of a severe brain bleed. Examples of common brain bleeds include epidural hematomas, subdural hematomas, and subarachnoid hemorrhages. If these brain bleeds are not treated quickly, they could even be fatal. Some depressed skull fractures require emergency surgery to stop the brain bleeds and prevent permanent damage.
- Diastatic Skull Fractures: A diastatic skull fracture takes place along the suture lines of the skull. When babies are born, their skulls are not yet fused. The fusion of the skull takes place along these suture lines during the first couple of years of life. If a fracture occurs along these suture lines, this is termed a diastatic skull fracture. Because fusion of the skull occurs at a young age, diastatic skull fractures typically occur in newborn babies and toddlers. The long-term damage from a diastatic skull fracture is sometimes not evident until the child gets older.
- Basilar Skull Fractures: This skull fracture is always severe. In a basilar skull fracture, there is a break that occurs at the base of the skull. Those who have suffered a basilar skull fracture might have liquid draining from their nose or ears. This liquid is cerebrospinal fluid (CSF), which typically coats the brain and spinal cord. Individuals also usually have significant bruising around the eyes and behind the ears. A basilar skull fracture is generally diagnosed using an imaging scan such as a CT or an MRI. There could be associated injuries to the ears, eyes, or nose that complicate the recovery process. In some cases, individuals with a basilar skull fracture might even require emergency surgery. The prognosis following a basilar skull fracture is guarded and is dependent on the size of the break and the time it takes someone to seek medical care.
- Compound Skull Fractures: A compound skull fracture runs from the surface of the scalp all the way down to the brain tissue underneath. Because this fracture exposes the underlying brain tissue to the outside world, this is a medical emergency. There is an extreme risk that the brain tissue could become contaminated, leading to a severe and life-threatening infection. The longer the brain tissue is exposed, the higher the risk of a serious brain infection such as meningitis or encephalitis. These infections are typically treated with intravenous antibiotics and could take weeks to clear. Those who develop a brain infection may have a poor prognosis.
- Comminuted Fractures: 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. The patient is told to avoid any activity that could further injure the skull or the brain.
Some skull fractures are accompanied by a traumatic brain injury and could require an extended hospital stay. Establishing the type of fractured skull injury is essential for selecting the right treatment process. The kind of skull injury also impacts the prognosis and recovery.How Common are Skull Fractures?
Fractures in the skull are not terribly common. There are about 42,409 skull fractures seen in hospitals per year. However, some of them are cases of open head injury. This represents 1 in 6,413 people or about 0.02 percent of the population. It would be rare to have a fracture and not need some kind of medical attention.
A lot of the time, you would see motor vehicle accidents as the culprit in skull fractures. A head injury might lead to a fractured skull. Negligence might lead to long-term effects, traumatic brain injuries, or worse, wrongful death. Compensation should be in order because of the mountain of medical bills you might be facing.
The most significant risk of a broken skull is not the fracture itself but the proximity of the skull to the brain. The 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 the fracture.Causes of a Fractured Skull
Fractured skulls occur under a variety of conditions. They are commonly seen in car 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 fracture as well.Symptoms of a Fractured Skull
A skull fracture is almost always associated with pain so the individual will have some kind of a headache that can be localized to the site of the fracture or generalized throughout the head. 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 the 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.The Severity of a Fractured Skull Injury
Many broken skulls 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 the pressure in the brain and cause further brain damage.
Some of the 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 to minimize the damage to the brain inside and beneath the 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 Broken Skull
Before any test for skull fracture is done, the doctor must do a complete physical and neurological examination to look for signs and symptoms of a fractured skull. 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 the outcome of the patient’s mental status later.
The Glasgow Coma scale goes like this:
- Eye-opening response:
- Open with blinking—4 points
- Opens to verbal command—3 points
- Opens to pain not applied to the face—2 points
- No eye opening—1 point
- Verbal Response:
- Oriented—5 points
- Confused but can answer questions—4 points
- Inappropriate responses but with words discernible—3 points
- Incomprehensible speech—2 points
- No speech—1 point
- Motor Response:
- Obeys commands—6 points
- A 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.Tests for a Fractured Skull
There are several tests for a fractured skull that play an essential role in making the best diagnosis. A fractured skull is a severe injury and is often accompanied by a traumatic brain injury. Because of the dangers of a TBI, it is essential to diagnose a fractured skull as quickly as possible. Some of the tests that are used to diagnose a fractured skull, as well as the other associated injuries, include:
- Computed Tomography (CT) Scan
- Magnetic Resonance Imaging (MRI) Scan
All of these tests have their benefits and drawbacks, making them useful in certain situations. It is essential to understand how these tests are used to diagnose a fractured skull. If not used correctly, severe and even life-threatening injuries could occur.X-Ray in the Diagnosis of a Fractured Skull
An x-ray scan is one of the oldest imaging tools available; however, this test still plays a vital role in the diagnosis of a fractured skull. An x-ray produces images based on density and, because the bones are incredibly dense, a skull fracture is typically readily apparent on an x-ray image. Some of the skull fractures that might be diagnosed by an x-ray include:
- Linear skull fractures
- Diastatic skull fractures
- Basilar skull fractures
Some of the benefits of an x-ray include:
- The test is high-speed, taking only seconds
- An x-ray is inexpensive, making it readily available to everyone
- The radiation exposure from an x-ray is minimal
Some of the drawbacks of an x-ray include:
- The detail of an x-ray is minimal, and small injuries can be missed
- An x-ray is a two-dimensional image that could make it hard to interpret
In many cases, x-ray images are shot from multiple angles. By putting these angles together, doctors can spot numerous skull fractures that might have otherwise been missed. In some cases, an x-ray image is not enough, and other imaging is required.CT Scan Used to Spot a Fractured Skull
This test is essentially an x-ray in three dimensions. In a CT scan, a machine rotates around the body, taking a continuous x-ray image that is then translated into a three-dimensional picture. Some of the benefits of a CT scan include:
- Because the image is produced in three dimensions, the detail is markedly improved
- The test is still rapid, taking only a few seconds
- A CT scan can spot injuries that are often missed on an x-ray
There are several drawbacks that people need to know. Some of these include:
- A CT scan can still miss certain types of injuries
- The radiation exposure from a CT scan is high since it is an x-ray in three dimensions
A CT scan can spot all of the skull fractures discussed above. Also, a CT scan could pick up on a depressed skull fracture, which places the brain tissue at extreme risk. A CT scan could also spot other issues in the brain, including:
- Strokes stemming from the bone fracture
- Brain bleeds that might have occurred following the head impact
- Cerebral swelling
Some of these complications are life-threatening. In some cases, more information might be needed. Fortunately, other tests are available.The Role of an MRI in Fractured Skull Diagnosis
A Magnetic Resonance Image (MRI) is one of the most detailed imaging tests available. This image is produced using a series of powerful magnets and creates a picture based on how the various cells in the body respond to these magnets. This test for a fractured skull has numerous benefits, including:
- An MRI does not require any radiation to produce its image
- It provides an incredibly detailed picture that can spot even the smallest of injuries
Of course, there are also some drawbacks of which people should know. These include:
- Anyone with metal in their body cannot receive an MRI scan
- This test takes a long time to produce its image
- An MRI is extremely expensive
An MRI is capable of spotting even the slightest of nerve damage within the brain. Strokes, bleeds, diffuse axonal injury, abscesses, cerebral herniation, and bone fractures will all show up on an MRI. That makes this test crucial in the diagnosis of not only a fractured skull but also other head and brain injuries.Should I Be Worried?
When the index of suspicion 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 evaluate areas of skull fractures along with areas of brain damage or bleeding inside the brain from the fracture.
If bleeding is found, its location and size can be identified, and the individual can have a burr hole placed in the skull to drain the brain from any hematoma found. The CT scan is especially useful when it comes to looking at bones and finding areas of bleeding or bruising on the brain.Treatment of a Fractured Skull
The treatment of a broken skull 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 a traumatic brain injury, which can happen with any type of skull fracture.
In a linear 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.Going the Extra Mile
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, an 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 more profound 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 fractures lead to mild, moderate, or severe brain damage and permanent disability.Complications of a Fractured Skull
Many 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 the cause of the fracture also 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 fractured skull happens when there is bleeding inside the 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.Recovery After a Fractured Skull
The recovery process following a fractured skull can take many forms. Like other injuries, a fractured skull can range widely in its severity. Some skull fractures are going to take longer to recover than others. Some of the factors that will dictate the recovery following a skull fracture include:
- The location of the skull fracture
- The number of the skull fractures
- Whether or not there are any associated injuries
- The overall health of the individual
These factors are going to impact the recovery process both in the hospital and once the individual goes home. What does the recovery process following a fractured skull look like?The Initial Recovery: In the Hospital
In the hospital following a fractured skull, there are going to be a few different issues that will impact the recovery process. Some of the challenges following a fractured skull include:
Pain Management: The scalp and brain tissue are full of nerves. This can make a fractured skull an incredibly painful injury. Some of the steps of pain management include:
- Anti-inflammatory medications to help relieve the swelling such as Tylenol and Motrin
- Opioid pain medications such as Vicodin or Percocet
- Possible IV narcotic pain medications including Morphine and Dilaudid
Pain management is going to be one of the most important initial steps following a fractured skull.
Localizing the Skull Fractures: The next part of the recovery process is going to be identifying the locations of all of the possible skull fractures. This will likely require imaging modalities such as an x-ray, a CT scan, or even an MRI. Every skull fracture needs to be identified because this will help the doctors decide whether or not the individual needs surgery.
Possible Surgery for a Skull Fracture: Surgery could also be a part of the recovery process following a fractured skull. Some of the reasons why an individual might need surgery include:
- There is active bleeding within the skull cavity
- Bone fragments from the skull have been displaced from their appropriate anatomic location
- There is a concern that the brain might be swelling within the skull cavity
Following surgery, individuals will take some time to wake up. Then, they will probably spend several days in the hospital before going home.The Healing Process At Home Following a Fractured Skull
Once someone arrives home following a fractured skull, the recovery process is going to continue. Family members will need to watch their loved one closely because he or she might continue to have some symptoms from their head injury. These include:
- Difficulty falling asleep at night
- Tossing and turning during the night
- Recurrent headaches
- Mild nausea
- Trouble focusing
- Pain around the fracture sites
In addition, there could be more serious symptoms that indicate someone needs the immediate attention of a medical professional. These include:
- Confusion, disorientation, and an altered mental status
- Active, intractable vomiting
- Changes in their hearing or vision
- Weakness or numbness in certain parts of the body
The recovery process following a fractured skull could take weeks or even months depending on the severity of the injury. Pain management will be important and individuals might require physical or occupational therapy to help them return to school or work. In addition, one of the major challenges of a fractured skull is the possibility of associated injuries.Dealing with Possible Associated Injuries
There are several common associated injuries that could be diagnosed along with a fractured skull. Some of these include:
- Facial fractures
- Jaw injuries
- A broken nose
- Vision changes
- Problems with hearing
- A traumatic brain injury
While any of these could require surgical repair, a TBI is the most serious injury that could accompany a skull fracture. A serious skull fracture could cause a penetrating injury of the brain via the bone fragments from the skull. When this happens, individuals could suffer a brain bleed that might require surgical repair.
The recovery process following a skull fracture associated with a TBI could require extensive rehab to help individuals regain lost motor or sensory function. Some people might never achieve a full recovery. Those who have suffered a TBI also have a higher chance of developing debilitating mental health disorders which might require long-term care.
Here is a video on what a fractured skull entails from Robert Jarchi:Sacramento Personal Injury Lawyer
I'm Ed Smith, a personal injury lawyer for Northern California. Skull fractures and brain injuries from car accidents can be tricky when included in your car accident claim. Make sure you have a lawyer helping you who has experience in winning over the jury with such injuries.
Images by Pixabay
Editor’s Note: This page has been updated for accuracy and relevancy [cha 11.18.19]