Skull Fracture

First aid for a suspected skull fracture

1. Call 911 or your local emergency number if the person has any red-flag sign above.
2. Do not move them if a neck or spine injury is possible, unless they are in danger. Keep the head and neck still and in line with the body.
3. Check breathing. If they are unresponsive and not breathing normally, start CPR.
4. Control bleeding from scalp wounds with gentle pressure using a clean cloth. If you feel a dent or bone fragments, press around the edges of the wound, not on it.
5. Do not remove any object stuck in the wound.
6. Do not block fluid draining from the nose or ears.
7. If they vomit, roll them onto their side while keeping the head and neck aligned.
8. Stay with them and note what happened and any change in alertness.

Types of skull fracture

A fracture of the temporal bone on the side of the head can tear an artery underneath, causing an epidural hematoma, a bleed that can be fatal within hours without surgery. People may seem fine at first (a "lucid interval") before deteriorating.

Skull fracture symptoms

• Pain, swelling or a boggy lump at the impact site; sometimes a visible dent
• Bleeding from a scalp wound, nose or ears
• Headache, nausea and vomiting
• Confusion, drowsiness, loss of consciousness or seizures

Signs of a basilar skull fracture

• Raccoon eyes: bruising around both eyes, appearing hours after injury
• Battle sign: bruising behind the ear over the mastoid bone, often after a day or two
• Clear fluid from the nose or ear: leaking cerebrospinal fluid (CSF leak), which may taste salty
• Blood behind the eardrum, hearing loss, ringing, dizziness
• Facial weakness or loss of smell from cranial nerve damage

Diagnosis

• CT scan of the head is the main test. It shows fractures, bone fragments, air inside the skull and bleeding on the brain.
• Doctors use decision rules, such as the Canadian CT Head Rule for adults and PECARN rules for children, to decide who needs a scan.
• Neck imaging if a spinal injury is possible.
• Hearing tests for temporal bone fractures, and fluid testing if a CSF leak is suspected.

In infants with skull fractures and no clear explanation, doctors also consider the possibility of non-accidental injury and may do further checks. This is routine practice, not an accusation.

Treatment

Simple linear fractures

Adults and children with a simple linear fracture, no brain injury on CT and a normal neurological exam are often observed for a few hours and may go home with a responsible adult and head injury advice. Some are kept overnight.

Depressed and open fractures

• Surgery to lift the bone back, clean the wound and repair the brain covering, especially when the fragment is pushed in deeper than the skull's thickness, the brain is injured, or the wound is contaminated
• Antibiotics and a tetanus shot for open fractures

Basilar fractures

• Usually managed without surgery
• Most CSF leaks stop on their own within about a week; avoid blowing your nose, sneezing with the mouth closed and straining
• Surgery for leaks that persist, or for nerve damage in selected cases

Brain injuries

Bleeding on the brain, swelling or a traumatic brain injury are treated in hospital, sometimes in intensive care, and may need emergency surgery to remove a clot or relieve pressure.

Pain relief is usually acetaminophen (paracetamol) at the label dose. Ask before using NSAIDs or aspirin, which may increase bleeding risk.

Healing time and recovery

• Bone healing: linear fractures in infants and young children often heal in a few months; in adults healing takes several months, though the fracture line may stay visible on scans for longer.
• Rest: follow advice for concussion recovery: rest for a day or two, then a gradual return to activity.
• Sports: no contact sports until cleared by a doctor, often for several months after a fracture.
• Long-term: recovery depends mostly on any brain injury. Some people have headaches, memory or concentration problems, mood changes or hearing loss.

Complications

• Bleeding in or around the brain
• Brain infection or meningitis, especially with CSF leaks or open fractures
• Seizures
• Cranial nerve damage affecting smell, vision, facial movement or hearing
• In young children, a growing skull fracture, where the brain lining pokes through the gap and widens it over time

Frequently asked questions

What are the signs of a skull fracture?

Signs include a painful swelling or dent on the head, bleeding from the scalp, nose or ears, bruising around the eyes or behind the ears, clear fluid from the nose or ears, and symptoms of brain injury such as confusion, vomiting, drowsiness or seizures. Some fractures cause only local swelling and are found on CT.

How long does a skull fracture take to heal?

Simple linear fractures in young children usually heal within a few months. In adults, bone healing typically takes several months. Most people can return to normal daily activities sooner, but contact sports are usually avoided for months. Recovery time is often driven more by any brain injury than by the bone.

Can you survive a skull fracture?

Yes. Most people with skull fractures survive, and many simple fractures heal without treatment. The risk to life comes from associated brain injury, especially bleeding such as an epidural hematoma, which is why emergency CT scanning and monitoring after a significant head injury are so important.

What is a basilar skull fracture?

It is a break in the bones at the base of the skull, behind the eyes, nose and ears. Typical signs are bruising around both eyes, bruising behind the ear, clear fluid leaking from the nose or ears, and hearing loss. It usually heals without surgery, but the risk of meningitis needs monitoring.

Does a skull fracture always need surgery?

No. Most linear and basilar fractures heal without surgery. Surgery is needed for depressed fractures pressing on the brain, contaminated open fractures, persistent spinal fluid leaks, or bleeding on the brain that requires removal.