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Battle’s Sign USMLE Notes & Mnemonics contains all the high-yield points you need to know.

  • Battle’s sign: Postauricular ecchymosis (bruising behind the ear) indicative of basilar skull fracture.


  • Represents blood tracking along the path of least resistance from a fracture site in the posterior cranial fossa.
  • Fracture may involve the temporal bone and mastoid process. (Ref)

Clinical Relevance

  • Sign of basilar skull fracture, specifically longitudinal temporal bone fractures.
  • Associated with other signs of basilar skull fracture like Raccoon’s eyes (periorbital ecchymosis), hemotympanum, CSF otorrhea/rhinorrhea.


  • Clinical observation: Bruising behind the ear that appears 1-2 days after injury.
  • CT Scan: Imaging of choice for skull fractures.
Battle's sign Mnemonic
Battle’s sign Mnemonic

Mnemonic for Basilar Skull Fracture Signs: “BATTLE’S CRASH

  • B = Battle’s sign
  • A = Auditory canal blood (hemotympanum)
  • T = Tinnitus or hearing loss
  • T = Torn meninges (CSF otorrhea/rhinorrhea)
  • L = Loss of consciousness
  • E = Ecchymosis (Raccoon’s eyes)
  • S = Sugar (glucose) in CSF
  • C = Cranial nerve deficits
  • R = Ringing in ears
  • A = Anosmia (due to olfactory nerve damage)
  • S = Seizures
  • H = Halo sign (CSF on gauze pad)


  • Immediate: ABCs (airway, breathing, circulation), cervical spine stabilization.
  • Neurosurgical consultation: For management of the underlying skull fracture.
  • Antibiotics: Prophylactic treatment to prevent infections such as meningitis.
  • Tetanus prophylaxis: If indicated.
  • Monitoring and treatment: For potential complications like brain injury, CSF leak, and meningitis.


  • Infection: Meningitis, brain abscess.
  • Cranial nerve injury: Especially VII (facial nerve) with longitudinal fractures.
  • CSF Leak: Otorrhea or rhinorrhea, risk of meningitis.
  • Hearing loss: Due to damage to the middle ear or auditory nerve.


  • Variable: Depends on extent of injury and presence of additional intracranial injuries or complications.

Note: Battle’s sign may not appear immediately after injury, so a high index of suspicion should be maintained in the appropriate clinical context. Always consider associated injuries with basilar skull fractures. Keep updated with the latest trauma management guidelines.

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