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Depressed Skull Fractures

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It has often been said that the presence of fractures

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is not as important as the presence of underlying

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brain parenchymal or extra-axial collections.

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With regard to the patient's prognosis, and

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by and large, neurosurgeons do not do very much

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about routine non-depressed, non-comminuted fractures

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of the skull.

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However, when that fracture is open, in other

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words, when there is an opening from the skin

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surface to the fracture and then to the intracranial

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contents, then they will consider doing surgery

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because of the high risk of potential infection

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from the skin surface, which is usually dirty

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from the trauma, into the meningeal space

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through the fracture site. So open

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fractures and fractures that are depressed

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greater than one thickness of the skull.

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So let's say that the skull is 10 millimeters

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thick. If the fracture is depressed inward by

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greater than that 10-millimeter thickness of

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the skull and without overlap of the skull,

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then they're more likely to go into

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correct the depressed skull fracture.

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Simple fractures that are not greater than one thickness

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depressed inward are ones where they may do observation

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and maybe even prophylactic antibiotics if they're

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concerned about the possibility of an infection.

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Here is a CT scan, which shows a dramatic trauma

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to this patient's right side of the calvarium.

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So we're looking at the bone windows, and what

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we see is that these fracture fragments, comminuted

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fracture, are depressed greater than one width of the

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normal calvarium.

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So were they to just overlap just a

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little bit here and not depressed, greater

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than full thickness of the calvarium,

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these might be treated with observation

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rather than surgery. But because of their

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inward depression, greater than one thickness,

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this is an indication for surgery.

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This is also an indication for surgery.

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You note that

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in this example, there is an

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open wound to the skin surface.

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So this is a laceration leading to the fracture.

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And in fact, you even see some intracranial air

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here, suggesting that there is a communication from

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the outside world to the intracranial contents.

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This is an open fracture that the surgeons

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would correct and also treat locally

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with, you know, appropriate antibiotics.

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In this instance, we are not actually

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seeing anything intraparenchymal with this

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compound, comminuted, depressed fracture.

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The brain underlying it doesn't look that bad,

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so this would just be surgery to address the

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fracture rather than, for example, draining a

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hematoma or an epidural or a subdural hematoma.

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So depressed skull fractures where it's

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depressed inward but not greater than one

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skull thickness may be treated non-operatively

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if there's no evidence of dural penetration and

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there's depression that's not very significant.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Trauma

Neuroradiology

Emergency

CT

Brain

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