What are the indications for conservative treatment of a skull fracture?

From the Guidelines

Linear, non-displaced skull fractures without associated intracranial injury can typically be treated conservatively. Conservative management includes close observation, pain control with acetaminophen (500-1000mg every 6 hours as needed) or NSAIDs like ibuprofen (400-600mg every 6-8 hours), and rest. Patients should be monitored for 24-48 hours, either in hospital or at home with reliable caregivers who can check for warning signs such as worsening headache, vomiting, confusion, seizures, or focal neurological deficits. Follow-up imaging is generally not required unless symptoms worsen. Activity restrictions should include avoiding contact sports or activities with risk of head injury for 4-6 weeks.

Key Considerations

• The Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) are clinical decision tools that can help identify patients with mild traumatic brain injury who are at low risk of clinically important brain injury and do not require head CT imaging 1.
• The CCHR has been shown to have a sensitivity of 100% and specificity of 68.7% for predicting the need for neurologic intervention, while the NOC has a sensitivity of 100% and specificity of 25% for predicting clinically important brain injury 1.
• The NEXUS Head CT decision instrument has also been shown to be effective in identifying patients at low risk of intracranial injury, with a sensitivity of 100% and specificity of 24.9% for predicting the need for neurosurgical intervention 1.
• Patients with certain risk factors, such as age greater than 64 years, suspected open skull fracture, or signs of basal skull fracture, should undergo head CT imaging regardless of their clinical presentation 1.
• Conservative management is appropriate because most uncomplicated skull fractures heal well without intervention, as the skull has good blood supply and healing capacity. However, fractures that are depressed more than the thickness of the skull, open fractures, fractures with dural tears, or those with significant underlying brain injury require surgical intervention rather than conservative management.

Patient Monitoring

• Patients with linear, non-displaced skull fractures should be monitored for 24-48 hours for signs of worsening injury, such as worsening headache, vomiting, confusion, seizures, or focal neurological deficits.
• Follow-up imaging is generally not required unless symptoms worsen.
• Activity restrictions should include avoiding contact sports or activities with risk of head injury for 4-6 weeks.

Special Considerations

• Patients on anticoagulant or antiplatelet medications, such as warfarin or clopidogrel, may be at higher risk of significant intracranial injury and should be considered for imaging regardless of their clinical presentation 1.
• Intoxicated patients with minor head injury may require imaging regardless of their clinical presentation, as the absence of high-risk criteria in the CCHR and the NEXUS Head CT cannot alone eliminate the need for CT in these patients 1.

From the Research

Conservative Treatment of Skull Fractures

• Skull fractures can be treated conservatively in certain cases, with studies showing favorable outcomes in patients with non-missile injuries and no severe complications 2.
• A retrospective cohort study found that 63% of patients with skull fractures after traumatic brain injury were treated conservatively, with a favorable outcome in 73.3% of cases and a mortality rate of 13% 3.
• The decision to treat conservatively depends on various factors, including the type and severity of the fracture, presence of intracranial bleeding, and patient's overall condition 3, 4.

Indications for Conservative Treatment

• Simple depressed fractures without severe wound contamination, established infection, or brain or cerebrospinal fluid in the wound can be managed conservatively 2.
• Patients with no mass effect, no epidural hematoma, and no significant edema may be candidates for conservative treatment 3.
• The use of prophylactic antibiotics and antiepileptics in the management of depressed skull fractures is controversial, with varying practices across different regions and countries 5.

Complications and Outcomes

• Skull base fractures can be associated with critical complications, including cerebrospinal fluid leak, meningitis, and vascular injuries 6.
• The outcome of patients with skull fractures depends on various factors, including the severity of the injury, presence of intracranial complications, and timely management 3, 2.
• A more conservative approach to the treatment of skull fractures has been gaining acceptance, with improvements in diagnostic techniques and management strategies 4.