Plain Skull X-ray

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Dealing with Head Injuries written for patients

Synonym: SXR

Headache and head trauma are common presenting problems in both primary care and the Accident and Emergency department. Plain skull X-ray films (plain skull films) have largely been superseded by CT scanning and/or MRI scans in the context of both headaches and head injuries.[1] This is also true in paediatric patients.[2] Skull X-rays are, however, still useful in children in whom non-accidental injury is suspected to detect previous injuries.[1] 

There is also now useful literature on the pre-hospital management of head injury.[3][4] 

When to request a skull X-ray
Head injury or not
Clinical settings
Head injury
CT scanning is the recommended investigation and criteria for CT scanning are provided in the National Institute for Health and Care Excellence (NICE) guidance.[1] 
Non-head injury cases
  • Presence of a palpable vault abnormality which feels bony.
  • As part of an imaging protocol for specific clinical problems - eg, skeletal survey for myeloma. Many centres now prefer bone scans for this purpose.
  • Facial views after trauma to the facial skeleton, mandible or orbit, or the possibility of a metallic foreign body.

Skull films are not indicated routinely for the following indications:

  • Headache.
  • Possible pituitary problems - (CT/MRI preferred).
  • Possible space-occupying lesion.
  • Epilepsy.
  • Dementia or memory loss.
  • Middle or inner ear problems.
  • Nasal trauma - coned views may be requested by the appropriate specialist.
  • Sinus disease - mucosal thickening is a common incidental finding and not diagnostic.
  • Temporomandibular joint dysfunction - will not show disc abnormality, which is the most common cause of dysfunction.

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Skull films should be interpreted wherever possible by a doctor with specialised training and/or considerable experience in interpreting such films. In untrained hands approximately 10% of bony abnormalities are not recognised. The absence of a fracture on a skull film does not rule out the possibility of an operable intracranial haematoma in head injured patients, which is why CT scanning is the investigation recommended in significant head injuries.[1] All such findings must be taken in the context of the clinical condition of the patient.

Further reading & references

  1. Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults; NICE Clinical guideline (Jan 2014)
  2. Kim YI, Cheong JW, Yoon SH; Clinical comparison of the predictive value of the simple skull x-ray and 3 dimensional computed tomography for skull fractures of children. J Korean Neurosurg Soc. 2012 Dec;52(6):528-33. doi: 10.3340/jkns.2012.52.6.528. Epub 2012 Dec 31.
  3. Early Management of Patients with a Head Injury; Scottish Intercollegiate Guidelines Network - SIGN (May 2009)
  4. Hammell CL, Henning JD; Prehospital management of severe traumatic brain injury. BMJ. 2009 May 19;338:b1683. doi: 10.1136/bmj.b1683.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Laurence Knott
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Document ID:
2618 (v26)
Last Checked:
11/02/2014
Next Review:
10/02/2019

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