How Do I Recognize a Skull Fracture?

In my country, before starting a postgraduate training program, we have to work for a couple of years as a general practitioner. One year is done in a rural community and another one wherever you want. My second year, I worked with a team in a private clinic where many drunks arrived with injuries from fights or falls. One I will never forget is when a man who was one of those we saw almost every day arrived. He had a head injury that required stitches. The patient looked well despite his condition; he was oriented, responded well, and had no other apparent problems. After suturing and observing him for six hours, I decide to discharge him, and when giving the final indications, I realized that he was moving his head every time I talked. When I asked him about it, he said, “Dr. Nieves, since I fell, I don’t hear anything in that ear.” The patient had a trauma with brain injury that manifested itself in this way, even though his Glasgow Scale score was normal. Obviously, I was unable to discharge him, and he was subsequently evaluated by a neurologist and a neurosurgeon. Fortunately, this case was addressed in time and had no major complications. But it taught me not to neglect those kinds of details.

The easiest and quickest way to recognize a fracture is by taking an x-ray and a computed tomography of the skull. However, we are talking about exceptional situations in which it is not possible to obtain one easily, so we must know some signs that a skull fracture may present. When a fall with a blow to the skull occurs, you have to feel the entire area with both hands to look for any depression or decreased hardness of the skull. Many skull fractures do not require hospitalization or special treatment beyond common painkillers and rest. However, there are some signs that are important to keep in mind as they make us think of a more serious type of fracture. When the fracture is at the base of the skull, the characteristic sign is “raccoon eyes” . After the trauma, the patient has black circles under the eyes, which is actually a bruise that is forming inside the skull and is manifesting itself in this way.