Skull fractures can occur in the skull vault, base of skull, or facial bones as a result of traumatic brain or penetrating injuries. They are important to identify due to associated soft tissue injuries and implications for severity of trauma. Skull fractures are classified anatomically, by displacement, and number of fracture lines. Base of skull fractures often involve the temporal bone and can produce signs like CSF leakage. Facial bone fractures may be detected using McGrigor-Campbell lines on skull radiographs. Identification of fracture pattern and location aids management of potential complications.

1. Skull fracture

2. • Skull fractures are common in the setting of both closed traumatic
brain injury and penetrating brain injury.
• Their importance is both as a marker of the severity of trauma and
because they are, depending on location, associated with a variety
of soft tissue injuries.

5. • Terminology
• Skull fractures can be broadly divided in a variety of ways:
• anatomically
• base of skull
• skull vault (calvaria)
• associated with overlying wound
• open (compound)
• closed
• degree of displacement
• undisplaced
• depressed (5-10 mm)
• number of fracture lines/fragments
• linear
• comminuted

8. SKULL BASE FRACTURE
• Basilar fractures of the skull, also known as base of skull
fractures, are a common form of skull fracture, particularly in the
setting of severe traumatic head injury, and involve the base of the
skull.
• They may occur in isolation or often in continuity with skull vault
(calvarial) fractures or facial fractures.

9. Epidemiology
• The majority of basilar fractures occur as a result of motor vehicle
accidents, with sports injuries, falls and assault being other
frequently encountered antecedents .
• Clearly, the relative incidence and demographics affected will vary
widely depending on regional differences and mechanism.

10. Clinical presentation
-Skull base fractures are often encountered in the setting of severe
head injury and thus the damage to the underlying brain and/or
intracranial haemorrhage dominate the clinical presentation.

11. • 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:

12. • anterior cranial fossa fracture
• CSF rhinorrhoea
• raccoon eyes sign
• petrous temporal bone fracture
• Battle sign
• CSF otorrhoea
• otorrhagia

17. CLIVAL FRACTURES
• Clival fractures are uncommon skull base fractures resulting from
high-energy cranial trauma and are usually associated with other
skull vault fractures and brain injuries.

20. • Temporal bone fracture is usually a sequela of significant blunt head
injury.
• In addition to potential damage to hearing and the facial nerve,
associated intracranial injuries, such as extra-axial
haemorrhage, diffuse axonal injury and cerebral contusions are
common.
• Early identification of temporal bone trauma is essential to
managing the injury and avoiding complications.

21. • Clinical presentation
Temporal bone fracture is suggested by Battle sign (post-auricular
ecchymosis) and bleeding from the external auditory canal.
As the fracture can sometimes involve the ossicles, inner
ear and facial nerve, symptoms such as hearing loss, vertigo, balance
disturbance, or facial paralysis may be present.

22. Radiological findings
• air surrounding the temporal bone
• Fluid in mastoid cells

23. • Fracture of the petrous part of the temporal bone can involve or
spare the otic capsule(bony labyrinth)
Predictors of the involvement of the otic capsule are
Facial nerve paralysis
Cerebrospinal leak
Sensorineural hearing loss
Epidural hematoma
Subarachnoid hemorrhage

24. Management
• Mainly involves management of the facial nerve

25. Complications
• Post traumatic cholesteatoma
• Meningitis
• Epidural hematoma
• Subarachnoid hemorrhage
• Facial nerve palsy
• CSF rhinorrhea
• Perilymphatic fistula

28. OCCIPITAL CONDYLAR FRACTURES

29. • Occipital condylar fractures are uncommon injuries usually resulting
from high-energy blunt trauma.
• They are considered a specific type of basilar skull fracture and
importantly can be seen along with craniocervical dissociation

34. FACIAL BONE FRACTURES

37. • McGrigor-Campbell lines are imaginary lines traced across the face on
an occipitomental (Waters) view skull radiograph to assess for fractures
of the middle third (especially) of the face 3:
• first line is traced from one zygomaticofrontal suture to another, across
the superior edge of the orbits
• second line traces the zygomatic arch, crosses the zygomatic bone, and
traces across the inferior orbital margins to the contralateral zygomatic
arch
• third line connects the condyle and coronoid process of the mandible and
the maxillary antra on both sides
• fourth line crosses the mandibular ramus and the occlusal plane of
the teeth

39. Line 1:
• Look for
• Widening of the zygomatico-frontal sutures
• Fractures of the superior rim of the orbits
• ‘Black eyebrow’ sign due to orbital emphysema
• Opacification/air-fluid level in the frontal sinuses

40. • Line 2:
• Look for
• Fractures of the superior aspect of the zygomatic arch
• Fractures of the inferior rim of the orbits
• Soft tissue shadow in the superior maxillary antrum
• Fractures of the nasoethmoid bones and medial orbits

41. • Line 3:
• Look for
• Fractures of the inferior aspect of the zygomatic arch
• Fractures of the lateral maxillary antrum
• Opacification/air-fluid level in the maxillary sinuses
• Fractures of the alveolar ridge