Skull fractures in children: Clinical manifestations, diagnosis, and management

INTRODUCTION — The clinical manifestations, diagnosis, and management of skull fractures in children are reviewed here.

The approach to severe traumatic brain injury in children and skull fractures in children with inflicted injury is discussed separately. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Skeletal evaluation'.)

EPIDEMIOLOGY — Skull fractures result from direct impact to the calvarium and are important because of their association with intracranial injury, the leading cause of traumatic death in childhood. The incidence of skull fractures in children who present for outpatient evaluation of head trauma ranges from 2 to 20 percent [1]. The parietal bone is involved most frequently, followed by the occipital, frontal, and temporal bones. Linear fractures are most common, followed by depressed and basilar fractures.

The causes of skull fracture and the causes of head injury typically are not frequently separated in the literature except for infants, who are at increased risk of skull fractures from minor mechanisms of trauma [2-4]. The major causes of head injuries in children are [5]:

●Falls – 35 percent

●Recreational activities – 29 percent

●Motor vehicle crashes – 24 percent

Falls are a common cause of traumatic head injury in children younger than two years of age, whereas motor vehicle crashes and assault are more common in 4- to 17-year-olds [6]. Boys are more likely to sustain traumatic head injuries than are girls. Falls are the most common cause of isolated skull fracture in all children (81 percent in the <2-year-old age group and 48 percent in the 2- to 17-year-old age group) [7]. (See "Prevention of falls and fall-related injuries in children", section on 'General epidemiology'.)

Intentional injury is an important cause of skull fractures, particularly in young children. One retrospective study reviewed the medical records of 287 children (aged one week to 6.5 years) who were admitted to a metropolitan children's hospital with head injuries [8]. Intentional injuries accounted for 19 percent. The mean age was 0.7 years for the intentional injury group versus 2.5 years for the unintentional group. Subdural hematoma; subarachnoid hemorrhage; retinal hemorrhages; and associated cutaneous, skeletal, and visceral injuries are more common in intentional than unintentional head injury. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children".)

CLASSIFICATION — The location and pattern of a skull fracture depends upon the nature and site of the causative impact. Fractures may involve the flat bones (eg, frontal, temporal, parietal, occipital) or the base of the skull. Fractures are classified according to their appearance, location, degree of depression, and whether they are in communication with the air sinuses of the skull, which increases the risk of cerebrospinal fluid leak.

Linear — Linear fractures account for approximately 75 percent of skull fractures in children. They are single or multiple fracture lines that involve the thickness of the skull and may disrupt underlying vascular structures. They start at the point of maximum impact and spread but do not cross suture lines. Multiple linear fractures indicate multiple sites of impact or repetitive injury.

Comminuted — Comminuted skull fractures consist of multiple associated linear fractures. They usually result from larger forces of impact than do single linear fractures. Stellate or comminuted fractures of the occipital bone often result from repeated blows against an object, and may suggest child abuse. (See "Physical child abuse: Diagnostic evaluation and management".)

Depressed — Depressed skull fractures are the result of significant force and frequently are associated with underlying cerebral injury. They may result from blows over small areas (eg, from a hammer or heel of a shoe). The depressed bone can lacerate the underlying dura or penetrate the brain tissue [9]. Depressed skull fractures increase the likelihood of posttraumatic seizures and infection.

Open — Open skull fractures are skull fractures that permit communication between the skull and the outside of the scalp or mucosal surfaces of the upper respiratory tract. Open fractures increase the risk of central nervous system infection. The two types of open skull fractures are:

●Skull fractures that have an overlying laceration, also called compound fractures.

●Skull fractures that disrupt the paranasal sinuses or middle ear and may be associated with cerebrospinal fluid (CSF) rhinorrhea or otorrhea. The evaluation of suspected CSF rhinorrhea is discussed separately. (See "Nasal trauma and fractures in children and adolescents".)

CLINICAL MANIFESTATIONS — The presence of a skull fracture usually is suggested by the history and physical examination. The history may include penetrating trauma, intentional injury, or injury associated with loss of consciousness. The older child may complain of localized pain and swelling. The physical examination can include soft tissue swelling, hematoma, palpable fracture or skull defect, crepitus, or signs of basilar skull fracture. (See 'Basilar skull fracture' below.)

Patients with skull fractures are at risk for traumatic brain injury (TBI) with elevated intracranial pressure (ICP) and concussion. Thus, they warrant careful neurologic assessment. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Secondary survey' and "Acute mild traumatic brain injury (concussion) in adults", section on 'Clinical features'.)

Linear skull fracture — Linear fractures occur most frequently in the parietal bone but can occur in any bone of the calvarium. Of linear skull fractures, 15 to 30 percent are associated with TBI [1]. Most linear skull fractures have associated physical examination findings, including overlying hematoma or soft tissue swelling; the soft tissue swelling may not be present immediately after the injury [1].

Scalp hematomas are predictive of skull fractures in infants younger than one year of age [2,10,11]. In one prospective study of 422 asymptomatic infants with head injury, hematomas of the parietal or temporal regions increased the likelihood of underlying skull fracture, whereas hematomas of the frontal region did not (odds ratio: 38, 16, and 0.6 for parietal, temporal, and frontal hematoma, respectively) [12]. In addition, a stepwise relationship was noted between the size of the hematoma and the likelihood of skull fracture (odds ratio: 27, 5.5, and 3, for large, moderate, and small hematomas, respectively). However, most children with isolated scalp hematomas and no other clinical symptoms do not have a clinically important traumatic brain injury. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Scalp hematoma'.)

Depressed skull fracture — Bony defects or "step-offs" may be palpable in children with significantly depressed skull fractures [2]. Approximately 30 percent of children with depressed skull fractures have associated TBI [1,13]. The risks of dural tear and brain laceration increase with the depth of the depression. In addition to intracranial hemorrhage, complications of depressed skull fractures include compression of underlying brain parenchyma, intraparenchymal bone fragments, cerebrospinal fluid leak, growing skull fracture, and cosmetic deformity [13,14].

Basilar skull fracture — Basilar skull fractures involve the base of the skull. In children, they are associated with significant adverse outcomes. As an example, in an observational study of over 550 children with basilar skull fractures determined during emergency department evaluation for head injury, 14 percent were intubated for >24 hours, 13 percent underwent neurosurgery, and 6 percent died [15]. Distinct clinical findings are present in approximately 70 percent of cases.

The signs and symptoms of basilar skull fractures from most to least frequent include [15]:

●Blood behind the tympanic membrane (hemotympanum) (picture 1)

●Subcutaneous bleeding around the orbit (raccoon eyes) (picture 2)

●Subcutaneous bleeding over the mastoid process (Battle sign) (picture 3)

●Cerebrospinal fluid leak from the ear (CSF otorrhea)

●Cerebrospinal fluid leak from the nose (CSF rhinorrhea)

●Cranial nerve deficits leading to facial paralysis, anosmia, nausea, vomiting, vertigo, nystagmus, tinnitus, or hearing loss

Evaluation of CSF leakage — For children with basilar skull fractures with a suspected CSF leak based upon signs or symptoms, urgent neurosurgery consultation is indicated, and patients with possible CSF otorrhea also warrant otolaryngology consultation. Confirmation and localization of the fistula requires neuroimaging. The diagnosis and management of cranial cerebrospinal fluid leaks are discussed separately. (See "Cranial cerebrospinal fluid leaks".)

Growing skull fracture — Skull fractures associated with an underlying dural tear may fail to heal properly. Enlargement is caused by herniated brain, a leptomeningeal cyst, or dilated ventricles [16]. These fractures commonly are called growing skull fractures, traumatic encephaloceles, or leptomeningeal cysts. Neurologic findings or cranial growth asymmetry may be present if associated compression of the underlying brain is present.

The incidence of growing fractures is not known. In one study of 592 children with head injuries, the prevalence was 1.2 percent [17]. Growing skull fractures occur predominantly in children who are younger than three years of age and in whom the diastasis is greater than 3 to 4 mm [18-20]. They usually are detected within one year of an acute head injury as a localized swelling or palpable skull defect that increases in size [16,21]. However, they may go undetected for years and present with delayed onset of neurologic symptoms (headache, seizure, or neurologic deficit) [1,22,23].

DIAGNOSIS AND RADIOLOGIC EVALUATION — Skull fractures should be suspected in patients with the following findings:

●Localized tenderness and swelling of the skull or scalp, especially if associated with a palpable fracture or bony step off, skull defect, or crepitus

●Signs of basilar skull fracture:

•Blood behind the tympanic membrane (hemotympanum) (picture 1)

•Subcutaneous bleeding around the orbit (raccoon eyes) (picture 2)

•Subcutaneous bleeding over the mastoid process (Battle sign) (picture 3)

•Cerebrospinal fluid leak from the ear (CSF otorrhea)

•Cerebrospinal fluid leak from the nose (CSF rhinorrhea)

•Cranial nerve deficits leading to facial paralysis, anosmia, nausea, vomiting, vertigo, nystagmus, tinnitus, or hearing loss

●Altered mental status after a head injury

●Penetrating head injury

Imaging establishes the diagnosis of a skull fracture. Modalities for radiologic evaluation of children with suspected skull fractures include:

●Neuroimaging – When skull fracture is suggested by clinical findings in children with acute head injury, we recommend unenhanced computed tomography (CT) to provide rapid diagnostic confirmation. Three-dimensional reconstruction images increase the sensitivity of CT for detecting skull fractures [24]. Temporal bone CT without contrast, including fine cuts in the axial and coronal planes are indicated in children with signs of basilar skull fracture. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Imaging'.)

Head CT is preferred over simple radiography because it can identify both skull fractures and TBI. Although ultrafast magnetic resonance imaging (MRI) has shown potential for detecting skull fractures and TBI without radiation, it is not widely available, is less sensitive for detecting bone fracture, and is more costly [25].

Other clinical criteria for determining which children with minor head injury should undergo head CT are discussed separately. The threshold for obtaining a CT scan in infants younger than two years, particularly those younger than three months, should be lower than it is for older children. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Approach'.)

●Skull radiographs – Skull radiographs can be used to identify and classify skull fractures. However, CT of the head, either standard or three-dimensional projections, are more accurate for diagnosing pediatric skull fractures [26,27]. Furthermore, the absence of a fracture does not reliably exclude TBI. This was illustrated in a meta-analysis of 16 studies to evaluate variables that predict significant TBI in children with minor head trauma [28]. Although presence of a skull fracture was a good predictor of TBI, (RR 6.1, 95% CI 3.4-11.2), it was neither sensitive (59 percent) nor specific (88 percent) enough to perform well as a diagnostic test. Thus, plain radiographs should not be used as a screening test to determine whether a child with known head trauma should undergo CT to identify TBI.

Skull radiographs may be performed when the history of trauma is uncertain (eg, evaluation of suspected abuse), or to rule out the presence of a superficial foreign body [29]. However, they should only be performed when interpretation by a pediatric radiologist or specialist with similar expertise (eg, pediatric neurosurgeon) is available. Interpretation by other physicians is likely to have poor sensitivity and specificity. As an example, when reading skull radiographs of children younger than two years of age, pediatric emergency physicians identified skull fractures with a sensitivity of 76 percent and a specificity of 84 percent [30].

If plain radiographs identify a skull fracture, neuroimaging (CT or MRI) is warranted although the risk for serious intracranial injury in well-appearing children with a nondepressed frontal skull fracture appears to be low.

●Ultrasound – Preliminary observational studies suggest that bedside ultrasonography can detect skull fractures but reported sensitivity and specificity are not sufficient to replace CT as the diagnostic test of choice [31-36]. As an example, in a case series of 69 children with head injury warranting CT who also had point of care ultrasonography, ultrasound detected skull fractures with a sensitivity of 88 percent and specificity of 97 percent when performed by clinicians who received a one-hour focused training session [31]. The prevalence of skull fractures in this study was 12 percent.

Ultrasound may also have a role as a screening tool for detecting dural tears and other findings that are associated with growing skull fractures (eg, the abnormal pulsations of herniated brain or cerebrospinal fluid in the fracture diastasis) [19]. However, prospective data are lacking.

INDICATIONS FOR SPECIALTY CONSULTATION — Children with any one of the following conditions warrant consultation with a neurosurgeon with pediatric expertise:

●Depressed skull fractures (see 'Depressed skull fractures' below)

●Basilar skull fractures (see 'Basilar skull fractures' below)

●Linear skull fractures with >3 mm separation (see 'Isolated skull fractures' below)

●Skull fractures with an associated intracranial injury

●Growing skull fractures (see 'Growing skull fractures' below)

Children with basilar skull fractures and CSF leakage should also be evaluated by a pediatric otolaryngologist.

MANAGEMENT — Management is determined by the type of skull fracture.

Brain injury and major trauma — During initial care, children with skull fractures should be evaluated for signs of other traumatic injuries and traumatic brain injury (TBI) with increased intracranial pressure as discussed separately. (See "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" and "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Secondary survey'.)

Subsequently, these children should also be evaluated for underlying concussion. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis".)

Isolated skull fractures — Neurologically normal children, who have an isolated linear skull fracture with narrow margins (<3 mm separation) that is not depressed and who have no other injuries identified by neuroimaging, may be sent home without further intervention as long as clear discharge instructions are provided and the following discharge criteria are met [2,7,37-42]:

●No significant extracranial injuries

●No indications of intracranial injury

●Normal neurologic examination, including ability to arouse easily

●No concern for child abuse (see "Physical child abuse: Recognition")

●Residence in close proximity to the hospital and reliable caretakers who are able to return with the child if necessary

Discharge instructions should include:

●Closely observe the child for the first 24 hours after injury.

●The child should undergo reevaluation by their primary care provider in one to two days and follow up with a neurosurgeon within the first few weeks after the injury. Patients with a skull fracture should limit activities that make them feel worse and not participate in physical activities that pose a risk for reinjury until they are fully recovered or cleared by a physician.

●Seek immediate medical attention if the child does not awaken as usual; seems sleepy at unusual times; or has a seizure, persistent vomiting, difficulty with coordination, confusion, or a change in vision.

●The child should undergo reevaluation by their primary care provider in one to two days. Patients with signs of concussion should limit cognitive activities that make them feel worse and not participate in physical activities that pose a risk for reinjury until they are fully recovered. (See "Concussion in children and adolescents: Management", section on 'Initial approach'.)

Infants and young children under two years of age who have isolated skull fractures should be evaluated for growing skull fracture one to two months after the injury [1]. Fractures that have healed are not palpable, whereas unhealed fractures are palpable as a localized, often pulsatile swelling, or a palpable skull defect [16,43]. (See 'Growing skull fracture' above.)

In a meta-analysis of 21 studies that reported on outcomes of over 6500 children with isolated skull fractures identified by neuroimaging, only one child underwent emergency neurosurgery and no patient died [42]. Of the 569 children who received repeated neuroimaging, six had a new finding of intracranial hemorrhage, but none required operative intervention. Thus, the risk of clinically important TBI in neurologically normal children with isolated linear skull fractures and no concern for child abuse is low and hospitalization of these patients is usually unnecessary.

Complications — Most linear skull fractures heal without complication. Complications include formation of subgaleal or epidural hematoma.

●Formation of a subgaleal hematoma is the most common complication of linear skull fractures. Subgaleal hematomas cause localized swelling that may be extensive enough to cause anemia. They usually absorb without intervention.

●Formation of epidural hematomas is another complication of linear skull fractures. They may affect any bone of the skull, with a propensity towards certain regions. Fractures of the temporal bone that involve the middle meningeal artery may cause epidural hematomas of the temporoparietal region. Fractures of the occipital bone that involve a venous sinus may cause epidural hematomas of the posterior fossa.

Open skull fractures — The use of prophylactic antibiotics typically is recommended to prevent osteomyelitis in patients with open fractures [44]. Patients with skull fractures and overlying lacerations should receive antistaphylococcal antibiotics. Further management is determined by clinical status and evidence of TBI on CT of the head.

Basilar skull fractures — Children who have basilar skull fractures should be managed in consultation with a neurosurgeon and, in children with hemotympanum, middle ear effusion, or otorrhea, an otolaryngologist.

●Basilar skull fracture without cerebrospinal fluid (CSF) leakage – Children with basilar skull fractures and no evidence of CSF leakage or pneumocephalus should be managed according to their clinical status and evidence of other TBI on CT of the head.

Children with isolated findings of basilar skull fracture on CT, a normal neurologic examination including a Glasgow Coma Scale (GCS) of 15 (table 1), and no progression of symptoms during emergency department observation are at low risk for adverse outcomes and can be discharged home with a reliable caregiver and ensured follow-up that includes a hearing test and neurosurgical evaluation. As an example, among over 250 children with isolated basilar skull fractures on CT and normal neurologic status during emergency department evaluation for head injury, none died or went on to need neurosurgical or intensive care intervention (0 percent; 95% CI 0-1.4 percent) [15].

●Basilar skull fracture with CSF leakage – Approximately 2 percent of children with basilar skull fractures develop CSF leakage [45]. In addition to management based upon clinical status and other TBI, patients with basilar skull fractures and CSF leakage warrant a hearing test and, if not already immunized, should receive the pneumococcal vaccine because they are at high risk for pneumococcal meningitis [46].

Additional management of patients depends upon the duration of the CSF leak:

•Resolution within 7 days – These patients do not typically require prophylactic antibiotics but need to be followed closely by a neurosurgeon and advised to seek medical attention if fever or other signs of meningitis develop. As long as there is no facial nerve entrapment or ossicular disruption, surgery is not required and patients with normal neurologic status can be discharged home with a reliable caregiver and ensured follow-up that includes a hearing test.

Based upon retrospective observational studies in children, prophylactic antibiotics are not recommended initially for patients with basilar skull fractures after nonpenetrating head trauma, even when they have CSF leakage [47,48]. Observational evidence in children and adults does suggest that the risk of meningitis is significantly increased in patients with a CSF leak, especially when drainage lasts longer than seven days. However, early antibiotic prophylaxis does not appear to decrease this risk. (See "Skull fractures in adults", section on 'Basilar fractures'.)

•No resolution within 7 days – If otorrhea or middle ear effusion has not resolved within seven days, additional measures are determined by the otolaryngologist, often in cooperation with a neurosurgeon, and may include:

-Prophylactic antibiotics

-Lumbar drain to stop the leak by reducing intrathecal pressure

-Localization of the fistula using neuroimaging and operative repair

The use of prophylactic antibiotics in adults with basilar skull fractures and CSF leakage are discussed separately. (See "Skull fractures in adults", section on 'Basilar fractures'.)

Surgical intervention may be indicated sooner in patients with a CSF leak if a temporal bone fracture has caused entrapment of the facial nerve or disruption of the ossicles. However, most surgical intervention, if necessary for open basilar skull fractures, can be delayed [49].

●Basilar skull fracture with pneumocephalus – Pneumocephalus may occur acutely as a direct result of a basilar skull fracture or arise chronically because of a CSF fistula [50]. Although rare, progressive accumulation of air, especially when resuscitation requires delivery of positive airway pressure, can cause tension pneumocephalus accompanied by mass effect with increased intracranial pressure [51]. In patients without symptoms, bed rest with 100 percent oxygen to wash out nitrogen and decrease intracranial gas has been proposed [50]. Symptomatic patients typically require neurosurgical decompression.

Evidence is lacking regarding the use of prophylactic antibiotics in children with basilar skull fractures and pneumocephalus. However, limited evidence in adults indicate that prophylactic antibiotics do not appear to reduce the significant risk of meningitis [52]. Also, this situation is similar to children with a CSF leak where prophylactic antibiotics are not recommended as discussed above.

Complications — The complications of basilar skull fractures include hearing loss, cranial nerve impairment, and CSF leakage:

●Hearing loss – Hearing loss occurs in up to one-half of children with basilar skull fractures [53]. The hearing loss may be conductive or sensorineural. Conductive hearing loss is caused by perforation of the tympanic membrane, blood in the middle ear space, or ossicular injury; sensorineural hearing loss is caused by injury to the cochlear organ of Corti. (See "Hearing loss in children: Etiology", section on 'Trauma'.)

●Cranial nerve impairment – Cranial nerve impairment (typically nerves VI, VII, and VIII) is reported in up to 23 percent of children with basilar skull fractures [53-55]. In one series of 73 children, approximately one-half of the impairments resolved completely and one-half of the children had residual deficits [55]. (See "Sixth cranial nerve (abducens nerve) palsy" and "Facial nerve palsy in children".)

●Basilar skull fractures – Basilar skull fractures with underlying dural tears are associated with CSF leaks and increased risk for intracranial infection. Most CSF leaks resolve spontaneously within one week of injury. In retrospective studies, the incidence of meningitis after basilar skull fracture ranges from 0.2 to 5 percent [45,54,56]. No prospective studies have evaluated the risk of central nervous system infection, nor the time of onset of infection in patients with documented CSF leakage; however, meningitis is reported to occur months to years after injury [57]. The most common organisms are Streptococcus pneumoniae, group A beta-hemolytic streptococci, and Haemophilus influenzae [47].

Depressed skull fractures — All children with depressed skull fractures should be managed in consultation with a neurosurgeon to determine the need for surgical elevation of the depressed fragment. Greater depression is associated with higher risk of dural tear, cortical laceration, and a worse prognosis. However, elevation may not decrease neurologic deficits, seizures, or infection [13,14,58]. Thus, a nonoperative approach is recommended for children who have simple depressed skull fractures without associated intracranial hematoma and in whom the bone depression is less than 1 cm, especially when they are not in a cosmetically apparent region of the skull [13,14,58].

The risk for posttraumatic seizures within one week of a depressed skull fracture is approximately 20 to 25 percent. In patients who have not had a seizure but appear to be at increased risk for seizures, prophylaxis with levetiracetam or phenytoin/fosphenytoin reduces the risk of early posttraumatic seizures and may be used as described separately. (See "Posttraumatic seizures and epilepsy", section on 'Management of early seizures'.)

Based upon trials in adults, the use of anticonvulsants after head injury does not reduce the risk of late seizures or posttraumatic epilepsy. Thus, long term prophylaxis is not recommended. (See "Posttraumatic seizures and epilepsy", section on 'Prophylaxis against epilepsy'.)

Growing skull fractures — Growing skull fractures may require surgical intervention to close the underlying dura [21]. The management of growing skull fractures is not well studied; most evidence comes from case reports or case series. They may lead to neurologic deficits, cranial defects, or vascular anomalies [22,59]. Children with growing skull fractures are best managed by a neurosurgeon.

DISPOSITION — Hospitalization is warranted for all patients with skull fractures and any one of the following:

●Signs of increased intracranial pressure (eg, persistent neurologic deficits, headache, or vomiting)

●Intracranial injury

●Suspected child abuse (see "Physical child abuse: Recognition")

●Parents or caregivers who are unreliable or unable to return if necessary

Children who have depressed or widely diastatic skull fractures should be managed in consultation with a neurosurgeon. These children may also require admission to the hospital for observation and/or acute intervention [1].

Neurologically normal children who have an isolated linear skull fracture that is not depressed and has narrow margins (<3 mm separation) or an isolated basilar skull fracture and who have an otherwise normal CT of the brain may be sent home without further intervention as long as clear discharge instructions are provided and none of the above indications for hospitalization are present. Additional follow-up is determined by the type of fracture. (See 'Isolated skull fractures' above and 'Basilar skull fractures' above.)

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Acute pain management" and "Society guideline links: Pediatric trauma".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Skull fractures (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Clinical manifestations – The presence of a skull fracture usually is suggested by the history and physical examination. The history may include penetrating trauma, intentional injury, or injury associated with loss of consciousness. The older child may complain of localized pain and swelling. The physical examination may demonstrate:

•Scalp soft tissue swelling or hematoma

•Palpable fracture, skull defect, or crepitus

•Signs of basilar skull fracture (eg, raccoon eyes (picture 2), Battle sign, hemotympanum (picture 1), cerebrospinal fluid [CSF] rhinorrhea or otorrhea)

Most pediatric skull fractures are linear. (See 'Clinical manifestations' above and 'Classification' above.)

Patients with skull fractures are at risk for traumatic brain injury (TBI) with elevated intracranial pressure (ICP) and concussion. Thus, they warrant careful neurologic assessment. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Secondary survey' and "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Emergency department evaluation'.)

●Diagnosis – Imaging establishes the diagnosis of a skull fracture. When skull fracture is suggested by clinical findings in children with acute head injury, we recommend unenhanced CT to provide rapid diagnostic confirmation. (See 'Diagnosis and radiologic evaluation' above.)

Skull radiographs may be performed when the history of trauma is uncertain. However, they should only be performed when interpretation by a pediatric radiologist or specialist with similar expertise (eg, pediatric neurosurgeon) is available. If plain radiographs identify a skull fracture, neuroimaging (CT or MRI) is warranted although the risk for serious intracranial injury in well-appearing children with a nondepressed frontal skull fracture may be low.

The clinical criteria for determining whether children with minor head injury should undergo head CT are discussed separately. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Approach'.)

●Specialty consultation – Children with any one of the following conditions warrant consultation with a neurosurgeon with pediatric expertise:

•Depressed skull fractures (see 'Depressed skull fractures' above)

•Basilar skull fractures (see 'Basilar skull fractures' above)

•Linear skull fractures with >3 mm separation (see 'Isolated skull fractures' above)

•Skull fractures with an associated intracranial injury

•Growing skull fractures (see 'Growing skull fractures' above)

Children with basilar skull fractures and CSF leakage should also be evaluated by a pediatric otolaryngologist. (See 'Management' above.)

●Management – Hospitalization is warranted for all patients with skull fractures and any one of the following (see 'Disposition' above):

•Signs of increased intracranial pressure (eg, persistent neurologic deficits, headache, or vomiting)

•Traumatic brain injury

•Suspected child abuse

•Parents or caregivers who are unreliable or unable to return if necessary

Children who have depressed or widely diastatic skull fractures should be managed in consultation with a neurosurgeon. These children may also require admission to the hospital for observation and/or acute intervention.

Neurologically normal children who have an isolated linear skull fracture that is not depressed and has narrow margins (<3 mm separation) or an isolated basilar skull fracture and who have an otherwise normal CT of the brain may be sent home without further intervention as long as clear discharge instructions are provided and none of the above indications for hospitalization are present. Additional follow-up is determined by the type of fracture. (See 'Isolated skull fractures' above and 'Basilar skull fractures' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Allison Chantal Caviness, MD, who contributed to earlier versions of this topic review.