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

Management of Depressed Skull Fracture

All patients with suspected depressed skull fracture require immediate non-contrast head CT imaging to definitively diagnose the fracture and identify associated intracranial complications that determine management. 1

Immediate Diagnostic Evaluation

• Obtain non-contrast head CT immediately in all patients with suspected depressed skull fracture, as physical examination has 99% specificity for intracranial injury requiring intervention but cannot exclude significant pathology 1
• CT is the definitive diagnostic modality for detecting the fracture depth, associated intracranial hematoma, dural tear, underlying brain contusion, and venous sinus involvement 1
• Do not rely on skull radiographs—they have insufficient sensitivity and may mislead clinicians despite increasing the likelihood of intracranial lesions fivefold when positive 1

Indications for Surgical Intervention

Surgery is indicated when any of the following criteria are present:

• Depression >1 cm below the inner table of the skull 1, 2, 3
• Pneumocephalus with mass effect or tension pneumocephalus 1
• Dural violation with CSF leak or exposed brain 2, 3
• Significant underlying intracranial hematoma requiring evacuation 2, 3
• Gross wound contamination or established infection 3
• Focal neurologic deficits attributable to direct cortical compression by the depressed fragment (this is a neurosurgical emergency requiring elevation within hours) 4
• Severe comminution of the fracture 3

Conservative (Non-Surgical) Management

Conservative management is appropriate when ALL of the following criteria are met:

• No evidence of dural violation, exposed brain, or CSF leak 2, 3
• No pneumocephalus related to the fracture 2
• Depressed fragments <1 cm below the inner table 2, 3
• No significant intracranial hematoma 2, 3
• No gross wound contamination 2, 3
• No focal neurologic deficits from cortical compression 4

Conservative treatment consists of:

• Wound irrigation, debridement, and closure in the emergency department 2, 3
• Intravenous antibiotics for 5-7 days (nafcillin, ceftriaxone, metronidazole) 5, 2
• Seizure prophylaxis with phenytoin 5
• Hospital observation for 2 additional days off antibiotics before discharge 2
• Conservative management achieves equivalent neurologic outcomes and complication rates compared to surgical management in appropriately selected patients 6

Timing of Surgical Intervention

• Emergent surgery (within 2 hours) is required only for focal neurologic deficits from direct cortical compression by the depressed fragment 4
• Delayed surgery (4-12 days) can be safely performed in patients requiring cerebral perfusion pressure (CPP) management for elevated intracranial pressure, avoiding intraoperative hypotension during the acute phase of brain injury 5
• Most surgical cases can be performed as urgent procedures rather than emergencies, allowing for optimization of the patient's neurologic status 5, 6

Perioperative Management for Surgical Cases

• Use osmotic diuretics (mannitol or hypertonic saline) as temporizing measures for elevated ICP 1
• Maximize CPP management in the intensive care unit setting with ICP monitoring or clinical assessment before definitive surgery 5
• Serial neuroimaging is recommended postoperatively to monitor resolution of pneumocephalus or other complications 1

Critical 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 and some patients may still require intervention 7, 1
• Do not delay imaging—physical examination alone cannot exclude intracranial injury even with normal neurological findings 1
• Do not assume all depressed fractures require emergency surgery—only those with focal deficits from cortical compression are true emergencies; most can be managed urgently or conservatively 5, 4, 6
• Do not operate emergently on all open depressed fractures—selected patients without the surgical criteria listed above can be managed conservatively with excellent outcomes and no increased infection risk 2, 3, 6

Outcomes

• Conservative management of appropriately selected patients results in no increased risk of meningitis, late seizures, or CSF leak compared to surgical management 5, 2, 3, 6
• Focal neurologic deficits improve equally in both surgical and conservative groups when patients are appropriately selected 6
• The severity of traumatic brain injury and presence of focal neurologic deficits affect outcomes more than the choice between surgery and conservative management 6