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FIGURE 113.5 Basilar skull fracture. A: The arrow indicates a fracture of the left
temporal bone. The adjacent mastoid air cells are somewhat opacified. B: A small
extra-axial hematoma with associated pneumocephaly is seen (arrow ).

Neurosurgical consultation is mandated in patients with complicated,
basilar, open skull fractures or in fractures associated with underlying
intracranial injury. Diastatic fractures greater than 3 mm, burst fractures and
depressed skull fractures greater than 1 cm of depression are not likely to
heal without surgical reconstruction due to dural injury. Elective early
repair of dura and fracture fragments can prevent the late complication of a
growing skull fracture. Growing skull fractures are found months to years
after the initial injury and consist of craniocerebral erosion due to an
enlarging leptomeningeal cyst or vascular injury which leads to an
enlarging skull defect. The expanding defect may cause neurologic
deterioration over time.
Early- and late-onset posttraumatic seizures are increased in patients with
depressed skull fractures and retained bony fragments, as well as other
intracranial injuries as described above. The routine use of prophylactic
anticonvulsant medication is not recommended in patients with depressed
skull fractures.
Basilar skull fractures should be managed in conjunction with
neurosurgical consultation, but may necessitate otolaryngology consultation
as well. Despite the potential for involvement of the mastoid air cells or
paranasal sinuses, the risk of meningitis in basilar skull fractures is low.
There is no evidence to recommend the routine use of prophylactic
antibiotics in patients with basilar skull fractures with or without CSF
leakage. The risk of meningitis increased significantly in patients who had
persistent CSF leakage that did not resolve within 7 days. Neurosurgical
and otolaryngology intervention may be necessary in temporal bone
fractures associated with nerve palsies and persistent CSF leakage.
Interventions may include external CSF drainage to decrease intrathecal

pressure, operative repair of dural lacerations or of fistulas.
Additional evaluation and management of children with nonaccidental
head trauma are discussed separately. Please review Chapter 87 Child
Abuse/Assault .