Case history
Case history #1
A 19-year-old man is brought into the accident and emergency department by paramedics after falling off a 20-foot ladder at work. He is awake and alert, but amnestic to the event and reports loss of consciousness at the time of impact. In the emergency department the patient has a single episode of emesis, and has some repetitive questioning, asking the nurses several times if they have contacted his sister. On examination there is a tennis ball-shaped boggy haematoma over the left temple. There is blood in the auditory canal but no haemotympanum. His pupils are 4 mm and reactive, and his Glasgow Coma Scale score is 14.
Case history #2
A 7-year-old boy is brought into the accident and emergency department by his mother after falling off a jungle gym at the park onto concrete. She states that he may have been unconscious for a few seconds before he started crying. On presentation, the boy is crying but consolable. He has periorbital ecchymosis around his left eye and a small amount of blood in the left auditory canal. He describes his hearing as "fuzzy" in his left ear. His Glasgow Coma Scale score is 15, appropriate for age, and he moves all four extremities on command from his mother.
Other presentations
Skull fractures are usually the result of blunt force trauma such as falls, road traffic accidents, or assaults. Clinical signs may be absent or non-specific, such as scalp lacerations or swellings or tenderness on palpation. The one exception is basilar skull fractures, which may be associated with highly specific clinical signs such as blood pooling resulting in ecchymosis over the mastoid (Battle's sign) or periorbital areas ('panda' eyes), haemotympanum, cerebrospinal fluid leakage resulting in clear rhinorrhoea or otorrhoea, or cranial nerve injury resulting in facial paralysis or hearing loss.[1] However, it must be kept in mind that these signs are specific but not sensitive. Occasionally, skull fractures can be secondary to penetrating trauma such as gunshot wounds. In such cases, the type of fracture is dependent on the proximity of the weapon and type of ammunition used. Small-calibre high-velocity weapons result in punched-out lesions, while large missiles often result in wedge-shaped fractures with cantilevering of the fragments.
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