69 Repair of Skull Fractures
Khan Li

♦ Preoperative

• Preoperative intravenous antibiotics 30 min prior to incision
  
• Phenytoin (15 to 18 mg/kg) load
  
• Management of intracranial pressure: hyperventilation to pCO₂ of 25 to 30 mm Hg, mannitol 0.5 to 1 g/kg intravenously starting at time of skin incision, propofol (if indicated)
  
• If the fracture crosses a dural sinus, then blood for transfusions should be available in the room and an arterial line and large bore central line should be placed.
  
  
  

  
  
  

  Fig. 69.1 Elevation of depressed skull fracture by craniotomy (adults) or craniectomy (infants) circumferentially around margin of normal bone.

♦ Intraoperative

Planning of Incision and Shave

• As for standard craniotomy (see General Craniotomy, Chapter 2)
  
• Compound fractures may require débridement and irrigation with sterile saline prior to scrub and preparation

Incision and Scalp Flap

• Incision is infiltrated with lidocaine with epinephrine
  
• Incision is performed down through galea, with care not to plunge through areas that may not be covered by bone because of the nature of the fracture
  
• Raney clips or bipolar cautery are used to control scalp bleeding
  
• Fascial and muscle layers are incised sharply and dissected free from the skull
  
• Self retaining retractors are applied

Craniotomy (Fig. 69.1)

• Any loose bone fragments are carefully removed.
  
• For significantly comminuted fractures, larger fragments are marked with a marking pen to demonstrate the correct orientation for subsequent reconstruction.
  
• For compound fractures, the operative field is irrigated copiously with sterile saline.
  
• A burr hole is made outside the rim of depressed bone.
  
• If the depressed portions of the fracture cross a dural sinus, then a burr hole is placed either directly on top of the sinus or two burr holes are placed straddling the sinus away from the area of depression.
  
• A craniotomy is performed around the outer rim of the skull fracture to incorporate the entirety of the depressed skull fragments.
  
• If the craniotomy cannot completely contain the fracture, then the craniotomy should cross the fracture at a site where the fracture is not significantly depressed and the dura is likely to be intact.

Bone Flap Elevation

• The bone flap is carefully elevated while inspecting for any dural lacerations.
  
• Dural bleeding is controlled with bipolar cautery.
  
• Following evacuation of any epidural hematoma, dural tack-up sutures are placed around the outer rim of the craniotomy.
  
• If there are any dural tears, the dura is gently reflected and the subdural space is examined for any possible hematoma.
  
• If there are no dural tears, then inspection of the subdural space is at the discretion of the surgeon.
  
• Dural tears are repaired primarily or with the use of a free pericranial flap.

Depressed Fractures Spanning a Dural Sinus

• The bone fragments are reconstructed with titanium miniplates.
  
• Hemostasis is obtained.
  
• A central dural tack-up suture is placed and secured to bone flap.
  
• The bone flap is secured to the native skull with titanium miniplates.
  
• Closure is performed as per General Craniotomy, Chapter 2 except:
  
  
  
  
  • For compound fractures, any skin that does not appear viable is débrided until viable, bleeding scalp edges are visualized.
    
  • Vertical or horizontal mattress sutures with 2–0 or 3–0 nylon may be necessary to reapproximate the skin properly.

♦ Postoperative