Skull Fractures
                        ===============

The presence of a skull fracture increases the risk of significant
intracranial haematoma by a factor of five.(1)

The absence of a skull fracture, however, does not exclude ICH.(2,3)

One third of patients requiring immediate surgery on the basis of CT findings
and one half of patients who deteriorate whilst under observation have no
fracture demonstrable on plain radiography.(4,5,6,7)

It has also been shown that up to 80% of patients with abnormal CT scans after
minor head injury have normal skull X-rays.(8)

Skull fractures are not specific for ICH as less than one in ten patients with
skull fractures have demonstrable ICH. (9,10)

There are also additional problems obtaining good quality films in
uncooperative patients as well as false positive and false negative
interpretation of films when inexperienced staff interpret skull
x-rays.(11,12)

Plain radiography alone is therefore neither sufficiently sensitive or
specific to reliably predict ICH.
--Garry Wilkes, MD


 1 Masters SJ. Evaluation of head trauma: efficacy of skull films. AJR
1980;135:539-547.

 2 Bell RS, Loop JW. The utility and futility of radiographic skull
examination for trauma. N Engl J Med 1971;284:236-239.

 3 De Campo J, Petty PG. How useful is the skull x-ray examination in
trauma? MJA 1980;2:553-555.

 4 Stein SC, Ross SE. Mild Head Injury: A plea for routine early CT
scanning. J Trauma 1992;33:11-13.

 5 Masters SJ. Evaluation of head trauma: efficacy of skull films. AJR
1980;135:539-547.

 6 Costs and benefits of skull radiography for head injury: a national study
by the Royal College of Radiologists. Lancet 1981;2:791-795.

 7 Jones JJ, Jeffreys RV. Relative risk of alternative admission policies
for patients with head injuries. Lancet 1981;2:850-853.

 8 Livingston DH, Loder PA, Koziol J, Hunt CD. The use of CT scanning to
triage patients requiring admission following minimal head injury. J Trauma
1991;31:481-487.

 9 Masters SJ, McClean PM, Arcarese JS, Brown RF, Campbell JA, et al. Skull
X-ray examination after head trauma: Recommendations by a multidisciplinary
panel and validation study. N Engl J Med 1987;316:84-91.

 10 Mendelow AD, Teasdale G, Jennett B, et al: Risks of intracranial
haematoma in head injured adults. BMJ 1983;287:1173-1176.

 11 Rosenorn J, Duus B, Nielsen K, et al: Is a skull x-ray nesessary after
milder head trauma? Br J Neurosurg 1991;5:135-139.

 12 Thillainayagam K, MacMillan R, Mendelow AD, et al: How accurately are
fractures of the skull diagnosed in an accident and emergency department.
Injury 1987;18:319-321.