What is the management approach for a patient with a surgical depressed skull fracture?

Management of Surgical Depressed Skull Fracture

Patients with depressed skull fractures require immediate neurosurgical consultation and CT imaging, with surgical elevation indicated for open fractures, dural violation, depression >1 cm, underlying hematoma, sinus involvement, gross contamination, or focal neurological deficits from cortical compression. 1, 2

Immediate Assessment and Imaging

• Obtain non-contrast head CT immediately in all patients with suspected depressed skull fracture, as physical signs of skull fracture (palpable step-off, visible scalp deformity) have 99% specificity for intracranial injury requiring intervention 3
• CT imaging is the definitive diagnostic modality for detecting both the fracture and associated intracranial complications 3
• Assess for associated injuries including intracranial hematoma, dural tear, underlying brain contusion, and venous sinus involvement 1, 4

Indications for Surgical Intervention

Absolute indications for surgical elevation include:

• Open (compound) depressed skull fractures with dural violation 5, 6
• Depression >1 cm below the inner table of adjacent bone 2
• Underlying significant hematoma requiring evacuation 5
• Venous sinus involvement causing compression or thrombosis 4
• Gross wound contamination or established infection 6
• Focal neurological deficits from direct cortical compression by fracture fragment 2
• Pneumocephalus with mass effect or tension pneumocephalus 7

Timing of Surgical Repair

The traditional approach of emergent surgery can be modified in select cases:

• Emergent surgery (within 2 hours) is indicated when focal neurological deficits result from direct cortical compression, as immediate decompression can result in complete neurological recovery 2
• Delayed surgery (4-12 days) may be considered in hemodynamically unstable patients with severe traumatic brain injury (GCS 3-12) without significant mass effect, allowing optimization of cerebral perfusion pressure before operative intervention 5
• This delayed approach avoids intraoperative hypotension during the acute period of elevated intracranial pressure 5

Conservative Management Criteria

Select patients may be managed non-operatively if ALL of the following are met:

• Simple (closed) depressed fracture without dural violation 6
• No severe wound contamination or infection 6
• No brain tissue or CSF in the wound 6
• Minimal comminution of fracture fragments 6
• No focal neurological deficits 2
• Depression <1 cm below inner table 1

Approximately 56% of depressed skull fractures in one series were managed conservatively with outcomes comparable to surgical cases 6

Perioperative Management

Medical management during the acute phase includes:

• Antibiotic prophylaxis with broad-spectrum coverage (nafcillin, ceftriaxone, metronidazole) for open fractures 5
• Seizure prophylaxis with phenytoin or levetiracetam 5
• Cerebral perfusion pressure optimization through ICP monitoring and management 5
• Osmotic diuretics (mannitol or hypertonic saline) as temporizing measures for elevated ICP 7

Surgical Technique Considerations

• Coronal approach with free pericranial flap for frontal injuries allows adequate exposure and tissue coverage 8
• Craniotomy encompassing the depressed fracture rather than simple elevation provides better visualization 8
• Dural repair is essential when violated 8
• Cranioplasty using native bone fragments or titanium mesh depending on fragment integrity 8
• Continuous ICP monitoring from induction through recovery 4

Special Considerations

Venous sinus compression:

• Depressed fractures overlying the superior sagittal sinus can cause benign intracranial hypertension with papilledema 4
• Consider MRI venography and retrograde venous catheterization with pressure measurements if symptoms develop 4
• Surgical decompression results in immediate ICP normalization 4

Common Pitfalls to Avoid

• Do not dismiss closed depressed fractures as benign - neurologically intact patients with closed fractures not through the inner table were historically considered "clinically unimportant" but this definition varies across studies 1
• Do not delay imaging - physical examination alone cannot exclude intracranial injury even with normal neurological findings 1
• Do not rely on skull radiographs - they have insufficient sensitivity and may mislead clinicians despite increasing likelihood of intracranial lesions fivefold when positive 1

Follow-up

• Serial neuroimaging to monitor resolution of pneumocephalus or other complications 7
• Long-term follow-up (12-24 months) shows no increased complications from delayed surgical approach when appropriately selected 5
• Monitor for late seizures, infection, or CSF leak 5