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Basilar Skull Fracture: Basics & Beyond

Clinical exam signs are relatively specific for BSFs in comparison to other skull fractures, due to the proximity of the skull base to cranial nerves, vessels, and dura that lie in its vicinity. Loss of consciousness and GCS score variesdepending on the bone that is fractured, but also on the degree of the associated brain injury...

The positive predictive value in detecting a BSF is 100% for the Battle sign, 90% for a unilateral raccoon eye, and 70% for both bilateral raccoon eye and bloody otorrhea. Some specific signs of BSF may also be considered as predictive for intracranial hematomas in patients with GCS of 13-15 with a PPV of 78% for Raccoon eyes, 66% for Battle’s sign, and…

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 5 signs of a base of skull fracture

A base of skull fracture is a break in one or more bones of the skull floor (yes, that’s bones plural; there’s 22!). Trauma doctors care about recognising these because they indicate significant head trauma, and potential brain injury. Such patients are often unable to give a good history, through reduced consciousness.

Articles of Interest

A Review of Basilar Skull Fractures

It is of utmost importance to maintain a high clinical suspicion for temporal bone fracture in patients with traumatic head injuries. When suspected, the appropriate imaging should be ordered and associated injuries should be ruled out. Imaging may include either a maxillofacial CT (if facial trauma is noted) or a CT of the temporal bones (if maxillofacial imaging is not required). CT of the head is not the ideal initial imaging study. Missed fractures or delayed diagnosis can lead to debilitating symptoms for patients and potentially life-threatening complications.

Basal skull fracture and the halo sign

Although the value of this sign has been debated, an experiment showed that the sign was consistently visible when CSF concentrations were 30%–90% when mixed with blood. However, the sign was not specific to CSF: mixtures of blood with saline, tears or rhinorrhea also produced halos; filter paper, paper towel, coffee filters and linen all showed a ring.

Base of Skull Fracture

TBI management (including ICP control)...

Basilar fractures of the skull

Skull base fractures are often encountered in the setting of severe head injury and thus the damage to the underlying brain and/or intracranial hemorrhage dominate the clinical presentation. It is also rare to not obtain a CT of the brain in all such cases, however, historically a number of signs were described as being helpful in suggesting the presence of a base of skull fracture:

Basilar Skull Fracture in Kids – PECARN

If a child has exam findings concerning for BSF, do a head CT. If they have isolated BSF and a completely normal neurological exam after a period of ED observation, they have a low risk of adverse outcome and could be considered for discharge. Personally, I lean toward admission if a BSF is present.

Does Antibiotic Prophylaxis Prevent Meningitis in Patients With Basilar Skull Fracture?

In patients with basilar skull fracture, there is inadequate evidence to recommend for or against antibiotic prophylaxis in the prevention of meningitis, irrespective of cerebrospinal fluid leakage.

EM@3AM: Basilar Skull Fractures

Nasogastric tube placement is contraindicated with potential for intracranial placement.

Emergency Care BC

CT scan is positive in only ~50% cases (still the gold standard though).

Pediatric basilar skull fractures from multi-level falls: A systematic review and retrospective analysis

Multilevel falls are a common culprit for skull base fractures in pediatric populations. This systematic review outlines the lack of quality prospective studies with significant follow up in the current literature and the limited indications for otolaryngological involvement.

StatPearls

Basilar skull fractures, usually caused by substantial blunt force trauma, involve at least one of the bones that compose the base of the skull. Basilar skull fractures most commonly involve the temporal bones but may also involve the occipital, sphenoid, ethmoid, and orbital plate of the frontal bone.

TNT (To Not Treat) with Prophylactic Antibiotics for Basilar Skull Fractures

There is no support for routine prophylactic antibiotics in all patients with basilar skull fracture. Further RCTs are needed to assess its benefits and risks clearly.

Resources

London Health Sciences Centre

Basal skull fractures are often not detectable with skull x-rays or even CT scan. Basal skull fractures are most frequently diagnosed by clinical findings, making clinical assessment skills critical. CT may reveal suspicious fluid collections near a fracture if bleeding has occurred, or if damage to the dura resulted in a leak of CSF. The base of the skull contains a number of bony channels or foramen that permit the passage of blood vessels and nerves through the bottom of the skull. Clinical findings consistent with basal skull fracture are generally the result of bleeding or CSF leaks into one or more of these foramen or into the sinuses, or due to damage of the nerve that traverses the bony canals.