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Open Skull Fracture

Last Updated: February 18, 2020

The appropriate management strategy (operative versus nonoperative) for a depressed skull fracture continues to remain controversial.

Closed linear fractures, even if depressed, may be left untreated if there is no significant underlying expanding hematoma or mass lesion. A cosmetic deformity may justify operative intervention.

However, compound fractures (open to the outside with an associated skin laceration) coupled with suspected dural tears are indications for neurosurgical intervention because of their high likelihood of subsequent infection and abscess formation. Unfortunately, it is no reliable method to discern if the dura has been violated based on clinical findings or neurologic imaging, thus necessitating neurosurgical exploration.

It is reasonable to expect some form of underlying traumatic brain injury (TBI) with a skull fracture. TBI is commonly classified based on the level of severity of the initial injury and the associated sequelae. The classification of the TBI prognosticates the patient’s outcome in terms of risk of posttraumatic epilepsy, return of global function, and mortality.

The presence of focal neurologic signs is not an indication for surgical intervention for a skull fracture. Focal lesions typically arise from the force of the initial insult and result in a parenchymal hematoma or contusion. Elevation of the depressed fracture in these cases will not be therapeutic because the neurologic deficits are caused...