Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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Introduction:  
Skull fractures typically result from high 
energy injuries and can be linear, depressed, “ping-
pong” (typically in the pediatric population), or, in 
rare circumstances, elevated. Approximately 7.59 
million people worldwide experienced a documented 
skull fracture in 2019, with an incidence of 
approximately 98.9 per 100,000 population annually. 
Depressed skull fractures are fractures of the cranial 
vault in which the edges of the bone fragments are 
displaced from one another and one fragment is 
depressed into the intracranial space, altering the 
natural curvature of the calvarium. A skull fracture is 
not considered significantly depressed unless the 
fragment is displaced at least the width of the bone. 
This condition can be seen on imaging when the 
outer table of the depressed fragment is in line with, 
or deeper than, the inner table of the adjacent 
unfractured skull.  
 
 
 
Axial (Top) and sagittal (Bottom) CT scan demonstrating a 
depressed frontal bone fracture. This is “Patient 1” in the text 
below. 
 
3-dimensional CT scan reconstructed image of a circular 
depressed skull fracture. This is “Patient 2” in the text below. 
 
Causes and Mechanisms 
Although global data on incidence and 
mechanism of injury are currently lacking, regional 
studies agree that the most common mechanism of 
skull fracture is road traffic accident followed by 
falls or assault in some contexts.  
The majority of depressed skull fractures 
occur in the frontotemporal regions. They can be 
associated with additional intracranial injuries such 
as epidural or subdural hematomas, parenchymal 
contusions, or dural lacerations. Open depressed 
skull fractures have a higher risk of infection than 
other traumatic brain injuries, because of the risk of 
dural tear and cerebrospinal fluid leak due to 
displaced fragments. Open depressed skull fractures 
also have a higher risk of seizure, neurologic deficits, 
and death. 
 
Clinical assessment and diagnosis 
Primary trauma assessment must always be 
performed first, involving evaluation of airway, 
breathing, and circulation (ABCs) to ensure the 
patient is not at imminent risk and is stable for 
neurologic examination and imaging. 
The presenting signs and symptoms of 
depressed skull fractures are as varied as in traumatic 
brain injury, ranging from neurologically intact to 
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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comatose, depending on the extent of intracranial 
injury 
and 
polytrauma. 
A 
full 
neurologic 
examination should be performed, focusing on 
Glasgow Coma Scale / alertness and any motor or 
sensory deficits that may be secondary to injury 
caused by depressed skull fragments or related 
intracranial trauma. In cases of severe trauma or 
evidence 
of 
herniation 
syndrome 
(altered 
consciousness accompanied by a unilateral fixed and 
dilated pupil and/or hemiparesis), always remember 
to perform an abbreviated neurologic examination 
for injury localization before you intubate a patient. 
In severe cases, a depressed skull fracture 
may be diagnosed by simple inspection of the head, 
particularly in those with severe cosmetic defects or 
an open laceration over the fracture. A CT scan of the 
head is the gold-standard for diagnosing skull 
fractures and is helpful in evaluating accompanying 
intracranial injury. If a CT scan is not available, a 
skull X-ray can diagnose the bony injury, though it 
will not assist in evaluation of accompanying 
parenchymal injury. 
 
Management/ Treatment 
As with any traumatic injury, initial 
stabilization of the patient, including ABCs and a 
thorough primary and secondary exam, must be 
undertaken prior to management of depressed skull 
fracture. 
Indications for surgical management of 
depressed skull fracture include the following:  
• Depression that is greater than 5-10 mm. Often a 
good “rule of thumb” is that surgery is indicated 
if the outer table of the depressed edge is below 
the inner table of the corresponding edge.  
• Dural tears that require repair to prevent 
cerebrospinal fluid leak  
• Involvement of the frontal sinus, especially if 
there is severe comminution.  
• Significant pneumocephalus or intracranial 
hemorrhage, particularly in the context of 
neurologic deficits.  
 
Consider also significant or bothersome 
cosmetic 
deformities. 
Many 
depressed 
skull 
fractures 
can 
be 
managed 
nonoperatively, 
particularly in the setting of minimal depressed state, 
closed injury, absence of intracranial hematoma, and 
reassuring neurologic exam. 
Additionally, extreme caution should be 
taken before surgically addressing a depressed skull 
fracture adjacent to large venous structures such as 
the superior sagittal or transverse sinuses. Even 
simple fracture repair can be met with torrential 
bleeding while risking air embolism.  
 
Sagittal (Left) and coronal (Right) views of a depressed skull 
fracture that likely perforates the sagittal sinus, which runs at 
the midline along the interhemispheric fissure. When such cases 
are over the motor cortex, they can present with weakness of 
the leg or foot, making management decisions more difficult. 
Source: https://doi.org/10.1007/s00381-017-3485-z    
 
In the case of a minimally depressed skull 
fracture in a neurologically well patient with an open 
laceration 
over 
the 
fracture, 
conservative 
management may still be considered. The laceration 
should be thoroughly irrigated with several liters of 
sterile water or saline to wash out debris, then 
scrubbed with a chlorhexidine or other scrubbing 
agent, prior to multilayer incision closure, preferably 
with non-braided monofilament suture to reduce risk 
of infection. Though it is debated, a short course of 
prophylactic antibiotics may be considered for those 
who had conservative management of an open, 
minimally displaced fracture.  
A minority of depressed skull fractures 
present as “ping-pong” type in the pediatric 
population. This subtype of fracture has no 
fragments, but results from depression of a portion of 
an infant’s still thin and relatively pliable skull, in a 
smooth, bowl-like shape into the intracranial space. 
Non-surgical management options for ping-pong 
fractures such as vacuum assisted pumps have been 
successful in restoring skull contour in an ICU 
setting without the need for anesthesia. Most of such 
fractures - particularly when depressed less than 
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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5mm - can be managed conservatively with routine 
follow up.  
 
 
 
 
Axial (Top) and 3D reconstructed CT scan of ping-pong type 
fracture (Cases courtesy of Drs. Y. Glick and M. Mohamed, 
https://radiopaedia.org/articles/ping-pong-skull-
fracture?lang=us)  
 
Preoperative considerations 
After initial trauma evaluation, a discussion 
with the anesthesia team is essential to ensure safe 
preparation prior to surgical intervention. Timing of 
and methods of intubation may be affected by 
changes in neurologic status, airway compromise 
from polytrauma, or maxillofacial trauma. See 
Airway Management in Trauma. Despite the urgent 
nature of intervention for many significant traumatic 
brain injuries, a minimum of a primary trauma 
survey and basic blood work such as hemoglobin, 
platelet count, and coagulation factors should be 
completed prior to surgery to guide management. 
The need for blood transfusion can also be heralded 
by radiographic or physical exam findings such as 
swirl sign indicating possible active intracranial 
bleeding, pulsatile scalp bleeding, or fracture 
depression of subjacent venous sinuses.  
 
Elevation and repair of depressed skull 
fracture proceeds in the following steps:  
• Planning and communication with anesthesia and 
other providers 
• Clip hair, prepare and drape 
• Incision and exposure of the fracture 
• Burr holes and craniotomy around the fracture 
• Inspection and repair of the dura if necessary, and 
any other intracranial interventions such as 
hematoma evacuation 
• Reduction and fixation of the fracture 
• Placement and securing the bone flap in place 
• Scalp closure 
 
Steps: 
1. At least two functioning intravenous lines should 
be placed and available for access by the 
anesthesia team. If feasible, an arterial line 
allows for close hemodynamic monitoring. 
Placement of a central line may be considered if 
there is concern for hemodynamic instability or a 
high risk for sinus injury or a venous embolism, 
as described above. 
2. Communication with the Outpatient or Casualty 
departments and Anesthesia teams should be 
ongoing during surgical planning. A complete 
review of the above considerations should be 
repeated with the anesthesia and operative staff 
during a pre-incision time-out. 
3. Repair of a depressed skull fracture typically 
does 
not 
require 
significant 
specialized 
equipment or technology. Typical cranial 
operative equipment such as drills, monopolar 
and bipolar cautery to control bleeding, force-
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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control suction tips, and theater lights and/or 
headlights can be sufficient for a safe and 
effective surgery. In an ideal situation, a high-
speed drill with a craniotome and a footplate 
would be available for rapid and safe placement 
of burr holes and creation of a craniotomy flap. 
Hemostatic agents such as bone wax, cottonoid 
patties and gelfoam are ideally available to the 
surgeon. See Lateral Craniotomy for more details. 
4. Additional equipment preparations should be 
made based on pattern of injury and expected 
potential complications: Depending on the extent 
of parenchymal injury and additional traumatic 
brain injuries, a ventriculostomy drain may be 
required for ventricular decompression with a 
herniating brain or for intracranial pressure  
monitoring. An intraoperative ultrasound can be 
useful in many contexts, including to evaluate for 
intracranial hemorrhage, look for subdural 
hematoma to determine if an intact dura needs 
opening, or to guide ventriculostomy drain 
placement, if indicated. 
5. Positioning should be done such that the 
depressed skull is exposed, with enough room to 
extend around the fractured pieces if a 
craniotomy is planned. Typically, it is best if 
most of the depressed fracture is at the apex of 
the head, though consideration should also be 
taken for intracranial injuries, such as subdural 
hematomas, that may need to be accessed.  
Cranial fixation can be accomplished in several 
ways, depending on location of injury, age of 
patient, and access to resources. Pinning the head 
in a Mayfield cranial fixation may be considered 
in some circumstances; however, a safe 
craniotomy can be performed with the head 
resting securely on a horseshoe head frame, 
particularly for a simple pterional approach, and 
allows for positioning in the supine, prone, and 
lateral positions. If a Mayfield or horseshoe 
headrest is not available, cranial fixation may be 
accomplished with a combination of bumping 
and propping with pillows, blankets, or bumps 
+/- tape. As with any surgical procedure, assure 
that all of the patient’s body is secured in as 
neutral a position as possible, taking care to pad 
potential pressure points and avoid nerve 
impingement, particularly at the axilla and hips. 
A dynamic bed allows intraoperative patient 
manipulation; 
Trendelenburg 
and 
reverse 
Trendelenburg positions can assist with surgical 
exposure and safety. 
6. Give the patient a generous haircut with electric 
clippers to mitigate infectious risk and a wide 
exposure. Be sure to allow for extension of the 
initial incision if you decide this is necessary 
during the procedure. 
7. The type of incision will be guided by fracture 
location and exposure needed to repair the defect. 
If the fracture is small and only a fragment needs 
elevation, a simple linear incision over the 
fracture site is often adequate. For more 
extensive fractures or for patients who require 
additional intracranial interventions such as 
subdural or intracranial hemorrhage evacuation 
or frontal sinus exenteration, a more extensive 
incision may be more appropriate, including a 
full “reverse question mark” trauma flap incision 
or a bicoronal incision that extends over the top 
of the head from approximately 1 cm anterior to 
the tragus bilaterally. The entirety of the bony 
injury should be exposed with the incision, often 
requiring elevation and inferior reflection of the 
temporalis muscle. 
 
The scalp incision and flap should be adequate to expose all of 
the skull fracture. Source: 
https://doi.org/10.4103%2Fajns.AJNS_111_19  
 
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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Frontal skull fracture- the best incision in this case was a 
bicoronal craniotomy that exposed all of the frontal bones from 
the vertex of the skull (bottom of picture) to the upper orbits 
(top of picture.) Source: 
https://doi.org/10.1155%2F2014%2F879286  
 
8. Burr holes should be thoughtfully placed away 
from the fracture line but to allow for adequate 
bony elevation. Burr holes may be made with a 
perforator or manually with a matchstick drill bit, 
based on surgeon preference and indications for 
speed (such as active herniation or uncontrolled 
bleeding). If these tools are not available, manual 
burr hole drills and a Gigli saw may be used to 
create a craniotomy around the fractured 
fragments.  
9. For a simple linear depressed skull fracture, the 
depressed edges may be elevated directly and 
plated together for stabilization. Burr holes may 
be drilled to assist in elevation of the depressed 
edges or to elevate the depressed portion of a 
“ping-pong” fracture.  
10. For larger, more complex, or multi-fragment 
fractures, drill a craniotomy circumferentially 
around the fragments by connecting the burr 
holes with the cutting bit of an electric perforator, 
or with a Gigli saw. 
 
Circumferential craniotomy around all bony fragments 
involved in the fracture allows the fracture to be elevated safely 
away from the dura and brain, rather than risking damage by 
trying to elevate the fragments while they are adjacent to the 
brain (Patient 1). 
 
 
Circumferential craniotomy around the circular depressed 
fracture, once again avoiding manipulation of sharp bone 
fragments while they are in contact with the dura or brain 
(Patient 2). 
 
11. In cases of severe fragmentation or fragment loss, 
a craniectomy may be performed and the bone 
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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flap is removed. The defect is filled with titanium 
mesh, split graft donor bone, or allographic 
implant, depending on the situation. In resource-
limited settings, the defect may remain in place 
until a later date.  
The degree of bony work should also be 
guided by the need for intracranial exploration: if 
there is no evidence of intracranial hemorrhage 
or dural laceration, simple elevation of the 
fracture may be an option. Craniotomy or 
craniectomy may be required for evacuation of a 
subdural or intraparenchymal hemorrhage or for 
dural defect repair, if indicated. During bony 
elevation, it is important to carefully dissect dura 
from the underside of the calvarium to avoid 
inadvertent dural tears during exposure. 
 
The craniotomy flap should be carefully elevated off the dura, 
keeping in mind that the dura is often adherent to the bone or 
contiguous with the inner table periosteum. Care should be 
taken to scrape the periosteum/dural layer off the bone prior to 
elevation to avoid causing a durotomy. 
 
12. After the bony fragments are removed from the 
field, the dura should be thoroughly inspected for 
defects or signs of intraparenchymal injury. 
Evaluate for bleeding dural vessels that can 
contribute to epidural hematomas, and purplish 
discoloration which can indicate subdural 
hematoma. Touch the dura gently to assess its 
tenseness, to get a feel for blood under pressure 
or elevated intracranial pressure. Intraoperative 
ultrasound can be helpful in evaluating for 
intraparenchymal hemorrhages if preoperative 
imaging was equivocal or if dura is more tense 
than expected. Dura should be opened, in a 
cruciate or stellate fashion, for evacuation of 
subdural or intraparenchymal hemorrhages or if 
elevated intracranial pressure is suspected.  
 
Visual and tactile inspection of dura. There does not appear to 
be a dural defect or underlying hematoma in this case 
 
13. If the dura is opened, a similar visual and tactile 
evaluation 
should 
be 
performed 
of 
the 
parenchyma, paying special attention to bleeding 
cortical vessels and the pulsatility of the 
parenchyma. If the parenchyma herniates 
through the bony defect quickly, it may be 
necessary to extend the craniotomy, perform a 
partial lobectomy if parenchyma is non-viable, or 
plan for a craniectomy to accommodate the 
elevated intracranial pressure.  
14. The approach to dura closure depends on the 
severity of injury. For patients with minimal 
intracranial injury or simple subdural hematoma 
evacuations without extracranial herniation, the 
dura may be laid over the parenchyma or closed 
with suture via loose approximation. A water-
tight closure is typically not necessary unless 
exposure includes the posterior fossa. Small 
dural lacerations with no evidence of intracranial 
injury can be repaired primarily without subdural 
exploration. 
15. Fixation of the bone fragments or flap may be 
accomplished with cranial fixation plates or with 
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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sutures if plates are not available. In resource-
rich settings, in the pediatric population 
dissolvable plates or sutures are recommended 
for patients under 3 years of age to accommodate 
skull growth.  
 
Bone fragments are secured together using cranial fixation 
plates 
 
 
The reconstructed bone flap is affixed to the native calvarium. 
The burr hole defect was utilized for epidural drain placement 
(Black arrow). 
 
 
Bone fragments may be affixed to the periosteum native 
calvarium with sutures if cranial fixation plates are not 
available 
 
 
Multiple holes can be drilled in the native calvarium to secure 
the bone flap with suture. Source: 
https://doi.org/10.1007/s00381-017-3620-x  
 
Care should be taken to maintain the bony 
contour as much as possible by including all large 
fragments. Adding a slight bend to fixation plates 
can also improve contour and decrease the risk of 
skin dehiscence due to protruding foreign bodies. 
The reconstructed flap should then be fixed to the 
adjacent skull. 
16. In the setting of severe brain injury, suspected 
elevated 
intracranial 
pressure, 
or 
overt 
Elevation of Depressed Skull Fracture 
Megan E. H. Still, Joseline Haizel-Cobbina, Dickson Bandoh, Peter Waweru, Michael C. Dewan 
 
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parenchymal 
herniation 
intraoperatively, 
a 
craniectomy may be chosen, leaving the bone 
flap off prior to closure. In these instances, best 
judgment should be used in deciding whether to 
keep or discard the elevated flap. If the fracture 
was open with significant dirt and debris or if 
there are several small fragments, the flap may be 
discarded with future plans to replace it. This 
option may reduce the risk of infection after 
cranioplasty if the fracture was open and overtly 
contaminated 
and 
may 
result 
in 
better 
cranioplasty contour if the fracture was heavily 
fragmented. Alternatively, if the fracture was not 
open or fragmented, common practice is to save 
the elevated bone flap for future replacement, 
either in a designated tissue fridge if available or 
in the subcutaneous space in the abdomen if it is 
not. These decisions are more complicated in 
resource-limited settings, where alloplastic 
materials such as bone cement and titanium mesh 
are often not available.  
17. To preserve the bone flap in the abdomen, an 
incision can be made on the abdomen and 
dissection performed to create a space just 
superficial to the fascia of the abdominal wall. 
After placing the bone in this new subcutaneous 
cavity, the incision can be closed in layers. If the 
patient has a severe brain injury, take care to 
place the flap such that it would not interfere with 
the placement of a feeding gastrostomy tube.  
18. Closure type should be guided by patient age and 
concerns for secondary brain injury. An external 
ventricular drain may be left if there is concern 
for cerebral injury or edema, either based on the 
presenting 
neurologic 
exam, 
pre-operative 
imaging findings, or intraoperative behavior of 
the parenchyma. Intraoperatively, ventricular 
drains can be placed based on anatomic 
landmarks or with imaging guidance such as 
ultrasound or stereotactic navigation. Consider 
whether 
the 
patient 
needs 
postoperative 
intracranial pressure monitoring. We recommend 
placing a monitoring device (fiberoptic wire or 
ventricular drain) in the following situations: 
preoperative Glasgow Coma Scale of 8 or less, 
full or tight brain encountered during fracture 
elevation, radiographic evidence of cerebral 
edema, or anticipated additional operations 
needed to address polytrauma injury.   
19. Gentle suction drains such as Jackson-Pratt 
drains may be placed during closure, either 
subdural or subgaleal, depending on the extent of 
opening. If a subdural hematoma was evacuated, 
many advocate placing a drain to mitigate the risk 
of hematoma re-accumulation; this topic remains 
debated. In a low-resource setting, a soft latex 
drain such as a 12F Foley catheter with extra 
holes cut in it, attached to gravity drainage, is an 
acceptable alternative.  
20. Skin closure materials can be chosen based on 
incision location, surgeon preference, and 
available materials. A multi-layered approach 
should be undertaken with simple interrupted 
dissolvable suture used to close temporalis fascia, 
inverted dissolvable suture used to close galea, 
and a final dermal closure. Skin staples are a 
common choice for dermal closure provided the 
galea is closed separately. Non-absorbable suture 
such as monofilament nylon is also a good option 
to prevent bacterial growth on braided suture and 
allows for inspection of the incision prior to 
suture removal. Dissolvable suture is sometimes 
considered in the pediatric patient if intracranial 
trauma was minimal with minimal parenchymal 
swelling and no plan for re-operation (e.g. no 
need for cranioplasty at a later date). 
21. Patients who undergo surgical intervention for 
depressed skull fracture should be monitored in 
an intensive care unit in the immediate 
postoperative period. For those with ventricular 
drains or pressure monitors, intensive care is a 
requirement. 
Every 
1–2-hour 
neurologic 
examinations 
should 
be 
performed 
by 
neurologically trained staff, and the surgeon 
informed immediately of signs of decline in 
neurologic status. Close monitoring of fluid 
status and vital signs is important to maintain 
appropriate intracranial and cerebral perfusion 
pressures. While ventricular drains should be 
monitored hourly for intracranial pressure trends 
and output, subdural or subgaleal drains can be 
evaluated and output measured every 4-6 hours. 
Elevation of Depressed Skull Fracture 
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The surgical team should be notified promptly of 
any acute changes to drain output.  
22. After initial surgical intervention, the primary 
focus turns to prevention of secondary injuries. 
For patients with severe traumatic brain injury, 
trauma guidelines recommend a 7 day course of 
prophylactic antiepileptic medication, which can 
help prevent early post-traumatic seizures, 
though it does not improve long-term outcome. 
Some surgeons chose to prescribe a week of 
prophylactic antiepileptics to patients with 
moderate traumatic brain injury who underwent 
surgical intervention or were found to have 
intracranial 
hemorrhage. 
In 
addition 
to 
maintaining 
appropriate 
intracranial 
and 
perfusion pressure levels and fluid management, 
care should be taken when positioning patients, 
especially 
those 
who 
are 
comatose 
or 
experiencing motor deficits. Pressure points such 
as sacrum, hips, elbows, and heels should be 
padded, and a regular regimen of turning should 
be instituted to avoid pressure wounds. Special 
care should be taken to avoid pressure wounds on 
the posterior of the skull, particularly if the area 
has traumatic lacerations or abrasions. Finally, 
wound care should be tailored to the incision 
location, closure material, and context. A simple 
bandage may be used as barrier protection for the 
first 24-48 hours postoperatively, after which the 
incision may be left to air if the context is 
sufficiently clean. Care should be taken to keep 
the incision clean, dry, and not covered by hair, 
hats, or scarfs, until it is fully healed.  
23. Follow up times will vary depending on extent of 
injury and intervention, length of intensive care 
and hospital stay, and extent of persistent 
neurologic deficit. At a minimum, a patient 
should be evaluated approximately 10-14 days 
after surgery to ensure the incision is healing 
appropriately and there are no signs of early 
infection. A postoperative CT scan is often not 
necessary in the case of a simple skull fracture 
repair but may be desired to evaluate for ongoing 
resolution of intraparenchymal or subdural 
hematomas, particularly for those who are not 
neurologically intact.  
 
Outcomes: 
An isolated skull fracture typically presents 
with minimal symptoms or symptoms of concussion 
and has a good prognosis for recovery after surgical 
repair. Prognosis after depressed skull fracture is 
largely related to additional intracranial injuries 
and/or complications encountered intraoperatively. 
In many studies, most patients had good long-term 
outcomes after a brain injury with a depressed skull 
fracture; however, this is certainly influenced by the 
extent of parenchymal damage and secondary brain 
injury. 
Motor 
deficits, 
pneumocephalus 
on 
admission CT scan, pre-operative GCS<13, need for 
reoperation, and hospitalization longer than 3 days 
were found to be predictors of poor neurologic 
outcomes in one study. Persistent neurologic deficits 
may necessitate long-term physical therapy or a stay 
in an inpatient rehabilitation center during the 
recovery process. In resource-poor settings, long-
term rehabilitation by professionals is out of reach of 
most families, who find that the burden of care falls 
on them. Discussions around these situations can be 
very difficult and should be led by a member of the 
team who understands the needs and abilities of 
families in the local context. 
In addition to the outcomes related to brain 
injury, patients who undergo surgical repair of 
depressed skull fracture are at risk for postoperative 
infection (reported in 4-16% in some case reports), 
seizures (3-12%), and cerebrospinal fluid leak (3%). 
 
Pitfalls 
Fractures traversing the venous sinuses have 
unique risks. It is recommended to get a CT 
venogram, MRA or angiogram with venous flow 
phase for adequate evaluation. If these are not 
available, a knowledge of venous sinus anatomy as it 
relates to the fracture pattern is crucial. After 
evaluation, the decision to operate on these patients 
is based on the degree of venous flow compromise, 
location of the sinus involvement and the 
neurological status of the patients. Midline fractures 
over the “motor cortex” and sagittal sinus may 
present with ipsilateral or bilateral lower extremity 
Elevation of Depressed Skull Fracture 
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weakness due to impingement of the fracture on that 
portion of the “homunculus.”  
Neurologically stable patients with a closed 
fracture over a patent venous sinus can be observed. 
If the fracture is open, the patients should undergo 
debridement without elevation of the bone segment. 
However, neurologically unstable patients or those 
with severe deformity may require urgent elevation 
of the depressed bone segment. In this case, special 
preparations should be made in case of violating the 
sinus, including sinus paddies (comprised of 
surgicell and a pledget) to hold gentle pressure, 
suture to repair defects, and type and crossmatched 
blood available or in the room for transfusion if 
massive bleeding is encountered. Violation of the 
sinus also significantly increases the risk of an air 
embolism, so close communication with the 
anesthesiology team must be maintained: Notify the 
anesthesiologists if the sinus is entered and ensure 
continued monitoring of end tidal pCO2. If air 
embolism is suspected, rapidly flood the field with 
saline, turn the patient or bed such that the left side 
is down, and move the patient to the Trendelenburg 
position. 
 
Conclusion: 
Depressed skull fractures comprise a variety 
of injuries and can present as simply as a cosmetic 
deformity in an intact patient or accompany a severe 
traumatic brain injury. Considerations for operative 
management include whether the fracture is open or 
there is exposed bone, the significance of the 
displaced fragments, the patient’s neurologic status 
and severity of polytrauma, and suspicion or 
confirmation of additional intracranial injuries. The 
goal of surgical management includes elevation of 
the fractured bone fragments, evaluation and 
evacuation of possible subdural injuries, evaluation 
and repair of dural defects, and reconstruction of the 
normal round contour of the skull. Specific 
approaches to treatment and follow up will depend 
on severity of injury and resources available in each 
context. 
 
 
 
Megan E. H. Still, MD 
University of Florida 
Florida, USA 
 
Joseline Haizel-Cobbina, MBChB, MPH 
Vanderbilt University Medical Center,  
Tennessee, USA 
 
Dickson Bandoh, MBChB, FWACS 
Komfo Anokye Teaching Hospital 
Kumasi, Ghana 
 
Peter Waweru, MBChB 
Tenwek Hospital 
Kenya 
 
Michael C. Dewan, MD, MSCI 
Vanderbilt University Medical Center,  
Tennessee, USA 
 
October 2024 
