Depressed Skull Fractures

FACTS

 

HPI

Universal cranial ROS: HA, nausea, vomiting, falls, seizures, visual changes, speech changes.

PHYSICAL EXAM

Put on some sterile gloves, dig around their hair and evaluate for gross wound contamination. The major question is - can you see bone overlying the fracture? Is the dirty wound in continuation with the skull fracture? Take pictures.

IMAGING

  • evalute for proximity to venous sinus and comment on this when you are staffing. If proximal to dural venous sinus, what region? (makes a difference if first 1/3 or last 1/3.
  • evaluate for pneumocephalus on lung window
A/P
PRS to close the scalp and be available for surgery
If near frontal sinus, needs ENT to be involved to evaluate for leak via scope, also available for OR if needed
Tell ED to order broad spectrum ABx immediately, CNS penetrating
Eventually PRS may replace ABx with Unasyn or something
Operating vs. Not operating
If open: obligated to operate for early debridement and elevation
If ALL of the following criteria are met, reasonable to NOT operate
  • no pneumocephalus
  • no subdural or epidural hematoma
  • no sharp edged fragment on the fracture
  • no dural penetration
  • no gross wound contamination
  • no depression over motor area

Pros and Cons of Operating

notion image