Treatment of Depressed Skull Fractures
Patients with open (compound) depressed skull fractures greater than the thickness of the cranium should undergo operative intervention with elevation and debridement, while selected patients meeting specific criteria can be safely managed nonoperatively with antibiotics and close observation. 1
Surgical Indications (Absolute)
Operate immediately if any of the following are present:
- Depression greater than 1 cm (or greater than skull thickness) 1, 2
- Clinical or radiographic evidence of dural penetration 1, 2
- Significant intracranial hematoma requiring evacuation 1, 2
- Frontal sinus involvement requiring cranialization 1, 3
- Gross cosmetic deformity (especially anterior to hairline) 1
- Pneumocephalus related to the fracture 2
- Gross wound contamination 1, 2
- Exposed brain or cerebrospinal fluid leak 2
- Mass effect from bone fragments 4
Nonoperative Management Criteria
Conservative treatment is appropriate ONLY when ALL of the following are satisfied:
- No dural penetration on imaging 1, 2
- Depression less than 1 cm below inner table 1, 2
- No pneumocephalus 2
- No exposed brain or CSF leak 2
- No significant intracranial hematoma 1, 2
- No frontal sinus involvement 1
- No gross wound contamination 1, 2
Conservative protocol includes: wound irrigation and debridement, primary closure, intravenous antibiotics for 5-7 days, seizure prophylaxis with phenytoin, and observation for 2 additional days off antibiotics before discharge 4, 2. A 2022 prospective study demonstrated equivalent neurologic outcomes and complication rates between conservative and surgical management when these criteria are met 5.
Surgical Timing Considerations
Early operation (within 24-48 hours) is recommended to reduce infection risk 1, though delayed surgery (4-12 days) may be considered in specific circumstances to optimize cerebral perfusion pressure management in patients with severe traumatic brain injury and elevated intracranial pressure, provided there is no urgent mass effect requiring decompression 4.
Surgical Technique
The procedure consists of:
- Craniotomy encompassing the depressed fracture using a tailored coronal approach 3
- Thorough debridement of devitalized tissue, bone fragments, and foreign material 1, 3
- Elevation of depressed bone fragments 1
- Dural repair or plasty as needed 3
- Primary bone fragment replacement is acceptable if no wound infection is present at surgery 1
- Cranialization of frontal sinus if breached 3
Antibiotic Protocol
All patients (operative and nonoperative) require antibiotic coverage: nafcillin, ceftriaxone, and metronidazole for broad-spectrum coverage including anaerobes 1, 4. Continue for 5-7 days minimum 2.
Common Pitfalls
Avoid assuming nonoperative management is safe without confirming ALL criteria are met—even one violation (such as subtle pneumocephalus or 1.1 cm depression) mandates surgical intervention 1, 2. Do not delay surgery for cosmetically significant fractures or those with clear surgical indications, as infection risk increases with time 1. Never omit seizure prophylaxis, as all depressed skull fractures carry seizure risk regardless of management approach 4.