♦ Preoperative
- Control any significant scalp bleeding with temporary suturing or staples in the emergency room
- Review imaging studies: computed tomography (CT) scans with brain and bone windows; plain skull radiographs are rarely indicated
Special Equipment
- Padded horseshoe headrest (avoid pin fixation in patients with skull fractures)
Anesthetic Issues
- Antibiotics 1 hour prior to skin incision (i.e., cefazolin or vancomycin); administer immediately on admission if open wound
- Consider anticonvulsants (i.e., phenytoin or fosphenytoin) if associated cortical injury
♦ Intraoperative
Positioning
- Position head on headrest such that area of the fracture lies at the highest point of the skull’s convexity (Fig. 170.1)
- For convexity skull fractures, patient is typically supine with head turned toward contralateral side if cervical spine has been cleared; shoulder roll placed if necessary
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