Contribution of Skull Fractures to Traumatic Brain Injury: A Descriptive Analysis of Skull Fracture Classification Within the modified Brain Injury Guidelines

BackgroundSkull fractures are a common heterogenous finding in patients with traumatic brain injury (TBI). Their clinical significance, particularly of displaced and nondisplaced fractures, remains a topic of debate. This study aims to compare injury severity and clinical outcomes between patients with and without skull fractures.MethodsA retrospective study of prospectively triaged adult trauma patients with blunt TBI and radiographic evidence of intracranial hemorrhage (ICH) or skull fracture was performed. Patients were grouped based on the presence or absence of skull fracture. Multivariable logistic regression was used to identify independent predictors of mortality and radiographic progression.ResultsA total of 2543 patients were included in the analysis. Skull fractures were present in 24.6% (n = 626) of the population. Skull fractures were associated with increased incidence of midline shift and all ICH subtypes, SAH being the most prevalent. Skull fracture patients were more likely to have radiographic progression on CT head (CTH) and require neurosurgical intervention. Median hospital and ICU LOS were longer in skull fracture patients. Mortality was significantly higher in patients with skull fractures. Skull fractures were an independent predictor of radiographic progression, but not mortality. Displaced skull fractures had more severe outcomes than nondisplaced fractures; however, nondisplaced fractures had more severe outcomes than no fractures.ConclusionSkull fractures are associated with more severe patterns of intracranial injury, greater need for neurosurgical intervention, and higher mortality in patients with blunt TBI. This underscores the role of skull fractures as a clinically meaningful marker of injury severity and support continued caution in triage and management.