Depressed Skull Fractures

- Executive Summary

This topic is concerned with management guidelines of depressed skull fractures.

➡️Recommendations

Initial Management: (as a part of initial TBI management)

▪️ Avoid hypoxia.

² Strong recommendation.

▪️ Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2.

² Strong recommendation.

▪️ Avoid hypotension.

² Strong recommendation.

▪️ We recommend ICU admission and close neurosurgical observation with CT monitoring if needed (if not available, refer to a tertiary center). 

² Strong recommendation. 

▪️ The availability of equipped neurosurgery operating room is essential for management (if not available, refer to a tertiary center). 

² Strong recommendation.

▪️ Anti-seizure medications (ASM):

Consider the use of ASMs (e.g., phenytoin, valproate, or carbamazepine) to decrease the incidence of early PTS (within 7 days of TBI).

² Conditional recommendation

➡️Definitive management

▪️  surgical management may be indicated in Patients with open (compound) depressed cranial fractures (evidenced by CT) with:

▪️   Depression greater than the thickness of the cranium.

▪️   Clinical (CSF leak / hernia cerebri) or radiographic (pneumocephalus) evidence of dural violation.

▪️   Underlying significant intracranial hematoma or hemorrhagic contusions.

▪️ Frontal sinus involvement.

▪️  Gross cosmetic deformity.

▪️   Wound infection.

▪️  Dural venous sinuses compromise impeding blood flow as evident in 3D CT and MRV brain.

² Conditional recommendation

▪️  Surgery may be indicated for closed depressed skull fractures if:

-  the depression is causing a focal deficit through pressure on the adjacent cortex.

-  the closed fracture is depressed and causing a cosmetic abnormality, for example fractures over the forehead.

² Conditional recommendation

▪️  Surgery (if indicated) is recommended as soon as possible after stabilization and coverage of umbrella of antibiotics.

²  Strong recommendation

▪️  patients with open (compound) depressed cranial fractures may be treated conservatively in the absence of the previously mentioned surgical indications.

² Conditional recommendation