What is the appropriate treatment for a patient with a linear nondepressed skull fracture and no evidence of intracranial hemorrhage, in addition to laceration repair?

Management of Linear Nondepressed Skull Fracture Without Intracranial Hemorrhage

Discharge home is the appropriate treatment for this patient with a linear nondepressed skull fracture without evidence of intracranial hemorrhage after laceration repair.

Assessment of the Case

The patient is a 34-year-old man who:

• Was struck in the head with a brick
• Is awake and alert with normal mental status
• Has a 3 cm scalp laceration
• CT scan shows linear nondepressed skull fracture
• No evidence of intracranial hemorrhage

Treatment Algorithm

Primary Management

1. Laceration repair - Essential first step
2. Discharge home - Appropriate for uncomplicated linear skull fractures

Rationale for Discharge

• Linear nondepressed skull fractures without intracranial pathology have excellent outcomes with outpatient management
• The patient has normal mental status with no neurological deficits
• No evidence of intracranial hemorrhage on CT scan
• No signs of dural violation (no CSF leak, pneumocephalus)

Evidence Supporting Discharge

Research demonstrates that patients with uncomplicated skull fractures can be safely managed as outpatients. A retrospective study found that 96% of pediatric patients with closed head injuries including skull fractures and small intracranial hematomas were safely discharged within 24 hours without serious complications 1.

When to Consider Admission

Admission would be warranted if the patient had:

• Basilar skull fractures (11.6x higher risk of requiring inpatient admission)
• Need for IV fluids (4.3x higher risk)
• Depressed skull fragments (>1 cm depression)
• Dural violation or CSF leak
• Pneumocephalus
• Intracranial hemorrhage requiring monitoring
• Altered mental status

Why Other Options Are Not Appropriate

• Mannitol: Not indicated as there is no evidence of increased intracranial pressure or cerebral edema
• Oral steroids: No evidence supporting their use in uncomplicated skull fractures
• Admission for observation: Unnecessary for linear nondepressed fractures without intracranial pathology in an alert patient with normal neurological status

Discharge Instructions

1. Head injury precautions
2. Return immediately for:
   • Worsening headache
   • Vomiting
   • Altered mental status
   • Focal neurological deficits
   • Seizures
   • Clear fluid drainage from nose or ears

Common Pitfalls to Avoid

1. Unnecessary admission: Increases healthcare costs without benefit for uncomplicated cases
2. Failure to distinguish between linear nondepressed fractures (often managed outpatient) and depressed fractures (may require surgery if depression >1 cm)
3. Overlooking signs of basilar skull fracture which would warrant admission
4. Inadequate discharge instructions leading to delayed recognition of complications

The management approach should be different for depressed skull fractures, where surgical intervention is typically recommended for depressions greater than 1 cm or when there is dural penetration, significant intracranial hematoma, or wound contamination 2.