Back to Basics: Open & Depressed Skull Fractures
This post is not intended to be a comprehensive review of skull fracture types and management, but rather a discussion of two subtypes of skull fracture – open and depressed fractures. I chose this topic because it’s something I saw frequently during my recent elective working in an emergency department in Kumasi, Ghana. In the United States at trauma centers these patients are frequently managed immediately by neurosurgery; however, with few consultants available, I was able to be more involved in the prolonged care of these patients. If faced with these types of severe head/skull injuries in a community hospital, it is important to feel comfortable with the initial management.
Depressed skull fractures (section of skull below level of adjacent skull) are high impact injuries that lead to many complications including seizures, injuries to brain parenchyma, and CNS infections if open. The dura mater is often lacerated by the skull fragment, thus ANY sign of skin interruption above or adjacent to the injury site qualify the injury as an open fracture. Most depressed skull fractures are open until proven otherwise.
As with any trauma patients, those with significant intracranial injury require aggressive managements of ABC’s to minimize secondary brain injury, focusing on oxygenation and adequate perfusion. Treatment specific to the open fracture include:
-Prophylactic antibiotics: Vancomycin + Cefepime OR Vancomycin + Ceftazidime are first line (need to cover to S. Aureus, S. Epidermidis, and Pseudomonas)
-Anticonvulsants: The 2016 Brain Trauma Foundation guidelines recommend phenytoin to decrease incidence of early post-traumatic seizures. There is insufficient evidence to recommend levetiracetam over phenytoin. The loading dose of phenytoin is 15-20 mg/kg over 30 minutes; for levetiracetam 20 mg/kg.
Most open skull fractures with any of the following features are managed with emergent operative repair: fractures depressed more than the skull thickness or > 5 mm, signs of dural tear, pneumocephalus, underlying hematoma, or grossly contaminated wounds.
While we were often forced to attempt to clean grossly contaminated open skull fractures ourselves in Ghana with careful irrigation and covering due to difficulty attaining timely neurosurgical evaluation, probing or cleaning of the wound is not recommended outside of the OR.
Below are photos from a bad open skull fracture in Ghana with good outcome (3 weeks post injury) despite delayed neurosurgical treatment!
Carney, Nancy et al. “Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.” Neurosurgery 0:1–10, 2016
Heegaard, William and Michelle Biros. “Skull Fractures in Adults.” UpToDate. Last updated May 11, 2016.
“Skull Fractures” Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e, Chapter 257.