A 60 yo M presents to the ED for head trauma. He reports being struck in the head with a metal object while drinking. There is no reported LOC. GCS is 15 and exam reveals a large forehead laceration. A CT head is done. What's the diagnosis?  (scroll down for answer) 

Answer: Depressed Skull Fracture 

• Segment of skull depressed below level of adjacent skull
• Most associated w/ assaults, MVA, fall from height, or penetrating trauma
• Most common site = parietal bone
• Clinically significant fractures= pneumocephalus, open fracture, depressed below skull's inner table, location over major dural venous sinus or middle meningeal artery
• Complications= intracranial contusion/hematoma, extradural hemorrhage, infection, seizure
• Treatment
• Consult neurosurgery
• Update tetanus
• Prophylactic antibiotics (limited data) due to increased risk of infection - vancomycin, ceftriaxone
• Anticonvulsants (limited data) to prevent seizure

References:

Prakash A, Harsh V, Gupta U, Kumar J, Kumar A. Depressed Fractures of Skull: An Institutional Series of 453 Patients and Brief Review of Literature. Asian J Neurosurg . 2018;13(2):222–226. doi:10.4103/ajns.AJNS_168_16

Papa L and Goldberg S. Head Trauma. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9e; 2018.

Wright, David W., and Lisa H. Merck.. "Head Trauma." Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016