Skull X-ray — Study Notes
Views, systematic approach, key signs & common pathology
1. Standard Views
View Use
AP / Caldwell (15° angle) Frontal bones, orbits, frontal sinuses
Lateral Best for fractures, sella turcica, pineal gland calcification, air-fluid
levels
Towne's view (30° caudal angle, AP) Occipital bone, foramen magnum, petrous ridges
Waters view (occipitomental) Facial bones, maxillary sinuses, orbital floor
Submentovertical (SMV/base view) Skull base, foramina, sphenoid sinus
2. Indications
• Trauma — depressed/linear skull fracture screening (largely replaced by CT in modern practice)
• Suspected sinus disease — air-fluid levels, mucosal thickening
• Congenital/developmental anomalies — craniosynostosis, skull shape
• Metabolic/bone disease — Paget's disease, hyperparathyroidism, multiple myeloma
• Pituitary/sellar assessment — enlarged sella (limited; MRI preferred)
• Note: CT/MRI have largely superseded skull X-ray for acute trauma and intracranial pathology
3. Systematic Reading Approach
• Scalp — soft tissue swelling, foreign bodies
• Skull vault — cortical outline, thickness, lucent/sclerotic lesions
• Sutures — normal position/width, diastasis (raised ICP, trauma)
• Sella turcica — size, floor erosion (pituitary lesion)
• Sinuses — frontal, maxillary, sphenoid — opacification/air-fluid levels
• Facial bones & orbits — symmetry, fracture lines
• Pineal gland calcification — midline shift assessment (adults only, unreliable in children)
4. Key Radiographic Signs
Sign Meaning / Association
Ping-pong ball fracture Depressed fracture in neonatal/infant skull without break in
continuity
Battle's sign / raccoon eyes (clinical, Suggest basilar skull fracture — correlate with CT
not radiographic)
Hair-on-end appearance Thalassemia, sickle cell disease, severe chronic anemia — marrow
expansion
Salt and pepper skull Hyperparathyroidism — resorption giving mottled appearance
Punched-out lytic lesions Multiple myeloma
Cotton wool appearance Paget's disease — mixed lytic-sclerotic patches
Widened sutures Raised intracranial pressure (children), sutural diastasis in trauma
Enlarged/ballooned sella with Pituitary macroadenoma
thinned floor
5. Common Pathologies — Quick Reference
Skull Fracture
• Linear: sharp lucent line, no displacement; Depressed: fragment displaced inward — CT confirms depth
• Diastatic fracture: crosses and widens a suture — more common in children
Sinusitis
• Mucosal thickening, air-fluid level (acute), complete opacification (chronic)
Paget's Disease
• Thickened calvarium, cotton wool appearance, osteoporosis circumscripta (early lytic phase)
Multiple Myeloma
• Multiple well-defined punched-out lytic lesions without surrounding sclerosis
Hyperparathyroidism
• Salt and pepper skull due to subperiosteal and trabecular bone resorption
Craniosynostosis
• Premature suture fusion — abnormal skull shape depending on suture involved (e.g., scaphocephaly in sagittal
synostosis)
Pituitary Adenoma
• Sellar enlargement, double floor sign, cortical thinning — MRI needed for soft tissue detail
6. Common Pitfalls
• Normal vascular grooves and sutures can mimic fracture lines — fractures are usually sharper, more lucent, non-
branching
• Skull X-ray has poor sensitivity for intracranial injury — a normal film does NOT exclude significant brain injury
• Pineal calcification is unreliable as a midline marker in children (often not yet calcified)
• Wormian bones (extra sutural bones) are a normal variant, but excessive numbers associate with osteogenesis
imperfecta, hypothyroidism