Depressed Skull Fracture

'Bony' window levels on CT scan clearly demonstrate the depressed fragments

This injury is caused by a blow from a sharp object. Since diffuse 'deceleration' damage is minimal, patients seldom lose consciousness.


There is no overlying laceration and no risk of infection. Operation is not required except for cosmetic reasons. Removal of any bone spicules imbedded in brain tissue does not reverse neuronal damage.


A scalp laceration is related to (but does not necessarily overlie) the depressed bone segments. Failure to detect a compound depressed fracture with an associated dural tear is likely to result in meningitis or cerebral abscess.


Double density appearance on skull X-ray suggests depression but tangential views may be required to establish the diagnosis. Impairment of conscious level or the presence of focal signs indicate the need for a CT scan to exclude underlying extradural haematoma or severe cortical contusion. Selecting bone window levels on CT scan will clearly demonstrate any depressed fragments.

Management Bone edges nibbled away until Treatment aims to minimise the fragments can be elevated and removed, risk of infection. The wound is

"" debrided and the fragments elevated within 24 hours from injury. Bone fragments are either removed or replaced after washing with antiseptic. Antibiotics are not Underlying dural tears , Burr hole essential unless the wound is may be stitched at edge of depression excessive]v dirtv or patched with pericranium excessively airty.

If the venous sinuses are involved in the depressed fracture, then operative risks from excessive bleeding may outweigh the risk of infection and antibiotic treatment alone is given.


Most patients make a rapid and full recovery, but a few develop complications: Infection occurs when treatment is delayed, or debridement inadequate, and may lead to meningitis or abscess formation.

Epilepsy: Early epilepsy (in the first week) occurs in 10% of patients with depressed fracture. Late epilepsy develops in 15% overall, but is especially common when the dura is torn, when focal signs are present, when post-traumatic amnesia exceeds 24 hours or when early epilepsy has occurred (the risk ranges from 3 to over 60%, depending on the number of the above factors involved). Elevation of the bone fragments does not alter the incidence of epilepsy.

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