Case history
Case history #1
A 19-year-old man is brought into the emergency room by paramedics after falling off a 20-foot ladder at work. He is awake and alert, but amnestic to the event and reports losing consciousness at the time of impact. In the emergency room 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 exam there is a tennis ball-shaped boggy hematoma over the left temple. There is blood in the auditory canal but no hemotympanum. 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 emergency room 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 4 extremities on command from his mother.
Other presentations
Skull fractures are usually the result of blunt force trauma such as falls, traffic accidents, or assaults. Clinical signs may be absent or nonspecific, 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 sign) or periorbital areas (raccoon eyes), hemotympanum, cerebrospinal fluid leakage resulting in clear rhinorrhea or otorrhea, 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-caliber 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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