Skull fracture

Disease Description (Causes and Symptoms)

• Definition and causes: A skull fracture is a condition in which the skull bone is cracked or broken due to trauma to the head. Major causes include traffic accidents, falls, sports injuries, and blows to the head.
• Major types and pathophysiology:
  • Linear fracture: A crack (fissure) in the continuity of the skull. Symptoms may be mild if there is no brain injury, but there is a risk of associated bleeding.
  • Depressed fracture: Bone fragments become depressed toward the brain, which may cause compression or injury to brain tissue and increased intracranial pressure.
  • Basilar skull fracture: A fracture at the base of the skull that may cause damage to nerve and vascular pathways, cerebrospinal fluid leakage, and facial or auditory nerve injury.
• Major symptoms:
  • Localized pain, headache, scalp laceration (bleeding), and localized depression (visible change in appearance)
  • Signs of a basilar fracture: periorbital bruising (raccoon eyes), bruising behind the ears (battle sign), leakage of clear fluid (cerebrospinal fluid) from the ears or nose, hearing loss, vertigo, facial paralysis, etc.
  • Associated symptoms: decreased consciousness, vomiting, seizures (convulsions), and focal neurological deficits — these suggest brain injury or intracranial bleeding
• Possible complications: Intracranial hematoma, cerebral contusion/cerebral edema, meningitis due to cerebrospinal fluid leakage, nerve injury (including the facial and auditory nerves), vascular injury (including carotid artery dissection and pseudoaneurysm), and post-traumatic epilepsy

Treatment Methods (Standard Treatment · Medications · Procedures/Surgery · Lifestyle Management · Precautions)

• Initial treatment (emergency):
  • Secure the airway, breathing, and circulation (ABCs), immobilize the neck, and assess for overall trauma
  • If an object is embedded, do not remove it yourself; stabilize it and arrange emergency transport
  • If fluid is flowing from the ears or nose, do not block it (examination and observation of drainage are necessary), and report it to medical staff immediately
• Diagnostic tests:
  • In an emergency, CT (non-contrast head CT) is the most sensitive. Plain X-rays may be used to identify fractures, but CT is the standard.
  • If necessary, MRI (for evaluating soft-tissue and nerve injury), CT angiography (CTA) when vascular injury is suspected, etc.
• Conservative treatment:
  • Linear fracture: If there is no cerebral hemorrhage or neurological abnormality, observation is performed (the decision between home and hospital observation depends on the condition). Precautions such as limiting alcohol and medications are necessary.
  • Basilar fracture (without cerebrospinal fluid leakage): Observe for 3–5 days, keep the head slightly elevated, and do not blow the nose or blow through the mouth. In some cases, prophylactic antibiotics may be considered.
• Medications:
  • Antibiotics (intravenously) are administered for open fractures with a high risk of infection or when cerebrospinal fluid leakage is present — the appropriate antibiotic is selected based on the infection risk and circumstances.
  • If the risk of seizures is high, short-term anticonvulsants (e.g., for up to 7 days) may be considered, depending on the clinical situation.
• Surgical treatment:
  • If a depressed fracture is depressed beyond the thickness of the skull or there is neurological deficit or severe contamination: Elevation or removal of bone fragments followed by reinforcement with autologous or artificial bone (cranioplasty); hemorrhagic lesions (intracranial hematomas) are removed through concomitant surgery.
  • If there is persistent or large-volume cerebrospinal fluid leakage or recurrent meningitis, surgical suturing and closure of the leakage site are performed.
  • If vascular injury (bleeding, dissection, or pseudoaneurysm) occurs, treatment by vascular surgery or interventional procedures is necessary.
• Lifestyle management and precautions:
  • Avoid strenuous activity, vigorous exercise, and alcohol (for several days to several weeks, adjusted according to the condition).
  • Avoid activities that increase intracranial pressure, such as blowing the nose, blowing through the mouth, or forceful breathing.
  • Do not block fluid coming from the ears or nose (follow the medical staff’s instructions).
  • Visit the emergency room immediately if headache, fever, vomiting, changes in consciousness, seizures, or focal paralysis occurs.
• Prognosis:
  • The prognosis is generally good when a simple linear fracture occurs alone.
  • When there is a depressed or basilar fracture or associated brain injury, the prognosis depends on the severity of the brain injury (complications such as infection, epilepsy, and neurological deficits may occur).

Checklist Before an Outpatient Visit (Items to Bring and Example Questions)

• Recommended items to bring:
  • Time and circumstances of the trauma (when and how the injury occurred)
  • A record of recent symptom changes (headache intensity, vomiting, dizziness, tinnitus, whether fluid is leaking, etc.)
  • Recent photographs (scalp laceration, depressed area, and traces of bleeding)
  • List of medications currently being taken (especially anticoagulants, antiplatelet agents, anticonvulsants, etc.)
  • Allergy information (medications, latex, etc.)
  • Medical history (existing neurological disorders, epilepsy, cardiovascular disease, etc.) and results of previous tests (CT/X-ray images and reports)
  • A guardian or family member who can provide information (helpful for describing symptoms and understanding the circumstances)
• Items that are useful to record for the outpatient visit:
  • Whether loss of consciousness occurred and its duration, and amnesia (before/after the event)
  • Bleeding or discharge (color, amount, and timing)
  • Whether seizures occurred and their form
• Materials to show the doctor during the outpatient visit:
  • Imaging (such as CT) and reports from the emergency room or another hospital
  • Photographs (the wound and depressed area)

General Example Questions to Ask the Doctor

• "What tests (CT/MRI) are currently needed for my fracture?"
• "Is this a situation that requires surgery, or can it be managed with observation alone?"
• "Do I need antibiotics to prevent infection or meningitis?"
• "Do I need to take anticonvulsants to prevent seizures? What are the side effects?"
• "When can I resume daily activities, exercise, and driving?"

Disease-Specific Example Questions

• "Clear fluid is coming from my ear (or nose). How can you confirm whether this is cerebrospinal fluid leakage? When would you recommend surgical repair?"
• "Could the depressed fracture area affect my nerves (for example, the motor cortex)? To what extent is recovery of neurological function possible?"