FIGURE 113.5 Basilar skull fracture A: The arrow indicates a fracture of the left temporal bone The adjacent mastoid air cells are somewhat opacified B: A small extra-axial hematoma with associated pneumocephaly is seen (arrow ) Neurosurgical consultation is mandated in patients with complicated, basilar, open skull fractures or in fractures associated with underlying intracranial injury Diastatic fractures greater than mm, burst fractures and depressed skull fractures greater than cm of depression are not likely to heal without surgical reconstruction due to dural injury Elective early repair of dura and fracture fragments can prevent the late complication of a growing skull fracture Growing skull fractures are found months to years after the initial injury and consist of craniocerebral erosion due to an enlarging leptomeningeal cyst or vascular injury which leads to an enlarging skull defect The expanding defect may cause neurologic deterioration over time Early- and late-onset posttraumatic seizures are increased in patients with depressed skull fractures and retained bony fragments, as well as other intracranial injuries as described above The routine use of prophylactic anticonvulsant medication is not recommended in patients with depressed skull fractures Basilar skull fractures should be managed in conjunction with neurosurgical consultation, but may necessitate otolaryngology consultation as well Despite the potential for involvement of the mastoid air cells or paranasal sinuses, the risk of meningitis in basilar skull fractures is low There is no evidence to recommend the routine use of prophylactic antibiotics in patients with basilar skull fractures with or without CSF leakage The risk of meningitis increased significantly in patients who had persistent CSF leakage that did not resolve within days Neurosurgical and otolaryngology intervention may be necessary in temporal bone fractures associated with nerve palsies and persistent CSF leakage Interventions may include external CSF drainage to decrease intrathecal pressure, operative repair of dural lacerations or of fistulas Additional evaluation and management of children with nonaccidental head trauma are discussed separately Please review Chapter 87 Child Abuse/Assault