6 Elevation of Depressed Skull Fractures

10.1055/b-0035-121752

6 Elevation of Depressed Skull Fractures

Anand Veeravagu, Bowen Jiang, and Odette A. Harris

Introduction

Depressed cranial skull fractures often result from high energy, blunt, traumatic impacts. Most depressed fractures are located in the frontoparietal region. Although clinical presentation is variable, approximately 25% of patients with depressed fractures present with loss of consciousness and clinical sequelae of intracranial hemorrhage. ¹

A depressed cranial fracture may be characterized further as “open” or “closed,” based on the integrity of the overlying scalp. Closed fractures, wherein the scalp is intact, may be treated nonsurgically if the depth of the depressed segment is less than the measured width of the calvarial bone adjacent to the fracture. Open fractures communicate with the external environment and, as such, are presumed contaminated. Surgical intervention is often required in these cases for debridement, repair of dural lacerations, cleansing of bone fragments, evacuation of underlying hematoma, and elevation of the depressed fracture.

Indications ²

Presence of an open, depressed fracture in an infant or child.
Depression of the fracture segment greater than 5 mm below the inner table of the adjacent calvarial bone in an adult.
Presence of gross contamination, significant extra- or intraaxial hematoma, and/or pneumocephalus suggestive of a dural tear.
Neurologic progression in the setting of a closed fracture may be due to an associated expanding hematoma or compressive effect of the depressed bone fragment. In this case, elevation of the fracture is indicated.
Depressed fractures crossing dural venous sinuses deserve special consideration. While compression of a dural venous sinus may induce elevated intracranial pressure and heighten the risk of venous thrombosis, the risk of hemorrhage with fracture mobilization may also be significant. Therefore, it is reasonable to observe a neurologically stable patient with a closed fracture overlying a dural venous sinus. Likewise, scalp debridement alone (without fracture elevation) is an option for a neurologically stable patient with an open fracture overlying a patent sinus. A neurologically unstable patient, however, should undergo elevation urgently.

Preprocedure Considerations

Radiographic Imaging

Computed tomography (CT) is the standard imaging modality used to assess calvarial integrity and associated intracranial injury in the acute setting. CT venogram (CTV) may be utilized to assess sinus injury.
Magnetic resonance imaging (MRI)/angiography (MRA) may be used to diagnose suspected vascular injury (e.g., to a dural venous sinus).
Anteroposterior and lateral skull radiographs are used rarely to delineate bony injury and/or the presence of missile fragments.
Preoperative imaging (Fig. 6.1).

Medication

Open fractures should be treated consistent with other open lacerations. This includes administration of tetanus toxoid and broad-spectrum antimicrobial prophylaxis.
If elevated intracranial pressure is suspected, additional management, in accordance with traumatic brain injury (TBI) guidelines, is recommended. This may include hyperosmolar therapy.
Antiepileptic drug (AED) prophylaxis is appropriate for the prevention of early seizures in the setting of TBI, with intracranial pathology identified on CT imaging.

Operative Field Preparation

Limited clipping of local hair is reasonable for a closed, compressed fracture. A wider approach may be necessary in the setting of an open, compound fracture with anticipated or known intracranial injury.
Standard sterile surgical technique is used to prepare the operative site.
Incisions are marked and infiltrated with 1% lidocaine with 1:100,000 epinephrine.
Prophylactic antibiotics are administered.
Availability of blood products should be dictated by the type of injury and planned surgical intervention. Rapid and significant blood loss is possible, for example, in the setting of a suspected dural venous sinus injury.