FACTS
This page is to be used as a general guide to the non-operative skull-base fracture occurring in numerous locations (frontal sinus, orbits, ethmoids, sphenoid, clivus), all of which have similar expectant management with monitoring for CSF leak.
For specific skull base fractures which are often operative, see also:
Tegmen Typmani DefectTemporal Bone FracturePHYSICAL EXAM
universal neuro exam
- raccoon eyes (periorbital ecchmoses)
- Battle’s sign: postauricular eccymoses
- close attention to cranial nerve exam (including lower)
- provoke CSF leak from nares / ears
- option 1: chin to chest: if feasible with the rest of polytruamas (i.e. don’t need to be flat for TLS precautions)
- option 2: log-roll
- patients will often be in cervical or TLS spine precautions, this is not a reason to not test. Can still roll over patient on their side/belly and have their nose be looking down.
A/P
- generally non-operative
- red top tubes to collect CSF
- consider pituitary labs (including Na+) if any proximity to sella
- Imaging: as above
- CT venogram if any fractures near dural sinuses → assess for traumatic DVST
- CTA head and neck to evaluate for any arterial injury associated with adjacent fractures and also should be done universally for screening given risk of concomitant blunt cerebrovascular injury unrelated to fractures
Facial fractures
- Counsel: risks of unrepaired facial fractures: infection, mucocele, sinusitis
- Indications for repair of anterior frontal sinus fractures:
- cosmetic deformity
- if injuries past just the anterior wall
Specific Fractures
Le-fort fractures
Clivus fractures
- transverse, longitudinal, oblique
- transverse:
- tend to affect anterior circulation
- longitudinal:
- tend to affect vertebro-basilar circulation, sometimes leading to entrapment
- worst prognosis
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