Question 14.3

This clinical sign was noted in a patient involved in a motor vehicle accident.

a)  What sign is shown below? 

b) What does it indicate? 

c)  What associated signs support the diagnosis mentioned in Question 14.3 b?

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College Answer

A clinical photograph of Battle’s sign was supplied.

b) What does it indicate? 
Base of skull fracture

c)  What associated signs support the diagnosis mentioned in Question 14.3 b?

•    CSF otorrhoea
•    Haemotympanum
•    Racoon eyes
•    CSF rhinorrhoea
•    Cranial nerve abnormalities


This image was misappropriated from the ACI website ( NSW Agency for Clinical Innovation).

Battle's sign (named after Dr William Henry Battle, rather than any association with warfare) apparently has a 100% positive predictive value for base of skull fracture.

Features associated with a base of skull fracture include several features which the college did not mention. I have tagged them on to the end of their list, for completeness:

  • CSF otorrhoea
  • Haemotympanum
  • Racoon eyes (adults call it "bilateral periorbital haematoma")
  • CSF rhinorrhoea
  • Cranial nerve abnormalities:
    • CNI damage (loss of olfaction)
    • CN II entrapment (visual field defects or blindness)
    • CN VII palsy (facial paralysis)
    • CN VIII palsy (deafness)
  • Blephaerohaematoma (i.e. of the eyelid)
  • Pneumoencephalus (more of a radiological finding)
  • Bloody otorrhoea
  • CSF otorrhoea


Pretto, Flores L., C. S. De Almeida, and L. A. Casulari. "Positive predictive values of selected clinical signs associated with skull base fractures." Journal of neurosurgical sciences 44.2 (2000): 77-82.


Tubbs, R. Shane, et al. "William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture: Historical vignette." Journal of neurosurgery 112.1 (2010): 186-188.


Katzen, J. Timothy, et al. "Craniofacial and skull base trauma." Journal of Trauma and Acute Care Surgery 54.5 (2003): 1026-1034.


Samii, Madjid, and Marcos Tatagiba. "Skull base trauma: diagnosis and management." Neurological research 24.2 (2002): 147-156.