What is the management for a patient with a depressed skull fracture and a Glasgow Coma Scale (GCS) score of 15?

Management of Depressed Skull Fracture with GCS 15

A patient with a depressed skull fracture and GCS 15 requires immediate CT imaging to assess for underlying brain injury, dural violation, and depth of depression, followed by neurosurgical consultation for operative planning, as depressed skull fractures are high-risk features that mandate imaging regardless of neurological status. 1

Immediate Diagnostic Evaluation

CT imaging is mandatory for any patient presenting with a depressed skull fracture, even with a GCS of 15, as this represents a high-risk criterion in validated clinical decision rules. 1

• The Canadian CT Head Rule identifies "suspected open skull fracture" as one of five high-risk predictors requiring CT imaging, with 100% sensitivity for predicting need for neurosurgery. 1
• The New Orleans Criteria similarly mandate CT for any physical evidence of trauma above the clavicle, which includes depressed skull fractures. 1
• In prospective studies, depressed skull fracture was specifically identified as a criterion where no patient without this finding required neurosurgical intervention, but patients with this finding had significantly elevated risk. 1

Surgical Decision-Making Algorithm

The decision to operate depends on specific CT findings and clinical features:

Indications for Urgent/Emergent Surgery:

• Depression greater than the thickness of the adjacent skull (traditional threshold, though evidence is limited). 2
• Open depressed skull fracture with dural tear, gross contamination, or significant underlying hematoma. 3
• Focal neurological deficits attributable to cortical compression require emergent cranioplasty within hours, as immediate decompression can result in complete neurological recovery. 4
• Mass effect from bone fragments or underlying intracerebral hematoma. 3
• Signs of CSF leak or dural violation. 3

Considerations for Conservative Management:

• Simple (closed) depressed skull fractures without dural penetration may be managed conservatively, particularly in younger patients, as surgical and nonsurgical treatment show no difference in seizure occurrence, neurological dysfunction, or cosmetic outcome. 2
• Delayed surgical repair (4-12 days) can be considered in select cases to optimize cerebral perfusion pressure management during the acute post-traumatic period, provided there is no significant mass effect, gross contamination, or urgent decompression need. 3

Prognostic Factors

Patients with GCS 13-15 at presentation have significantly better outcomes than those with lower scores. 5

• In a prospective study, patients with GCS 13 or higher had good long-term outcomes, while those below this threshold fared poorly. 5
• The presence of additional brain injury (hematomas, contusions) has significant negative impact on outcome and warrants urgent surgical intervention. 5
• Dural tear, cerebral contusions, wound infections, and seizures adversely affect recovery. 5

Hospital Admission and Observation

All patients with depressed skull fractures require hospital admission regardless of GCS score, as this represents a structural injury with potential for delayed complications. 1

• Even patients with GCS 15 and depressed skull fractures had an 8% rate of positive CT findings requiring intervention in prospective studies. 1
• The evidence supporting safe discharge after negative CT applies only to patients with mild TBI without skull fractures. 6
• Neurosurgical consultation should be obtained for all depressed skull fractures to determine operative versus conservative management. 3, 4

Antibiotic and Seizure Prophylaxis

For open depressed skull fractures, broad-spectrum antibiotic coverage is indicated (nafcillin, ceftriaxone, metronidazole regimen has been used successfully). 3

Seizure prophylaxis with phenytoin should be initiated for depressed skull fractures, particularly open fractures or those with underlying brain injury. 3

Common Pitfalls to Avoid

• Do not discharge a patient with a depressed skull fracture based solely on GCS 15, as the structural injury itself is a high-risk feature requiring imaging and potential intervention. 1
• Do not delay CT imaging to observe the patient, as depressed skull fractures require immediate radiographic assessment. 1
• Do not assume all depressed fractures require immediate surgery—simple closed fractures without dural violation may be managed conservatively, but this decision requires neurosurgical input and CT confirmation. 2
• Do not miss focal neurological deficits that may be subtle but indicate cortical compression requiring emergent decompression. 4