Depressed Skull Fracture

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Depressed skull fracture.

A depressed skull fracture is a break in a cranial bone (or "crushed" portion of skull) with depression of the bone in toward the brain, typically caused by direct impact with a small blunt object; usually seen in the parietal or temporal region of the skull. The brain can be affected directly by damage to the nervous system tissue and bleeding. The brain can also be affected indirectly by blood clots that form under the skull and then compress the underlying brain tissue (subdural or epidural hematoma). This type of fracture is clinically important as they can predispose to significant underlying brain injury and lead to complications such as infection and seizures. Any patient suspected of having a depressed skull fracture warrants prophylaxis for post-traumatic seizures (especially with a history of positive LOC), which consists of seven days of an antiepileptic drug, typically fosphenytoin. Depressed skull fractures are classified as either closed (simple fracture) or open (compound fracture), which can be managed surgically or non-surgically based on the criteria listed below.


Signs and Symptoms

The signs and symptoms of a depressed skull fracture depend on the depth of depression of the free bone piece. On physical exam scalp swelling may interfere or hide any palpable bone defects. Approximately 25% of patients sustaining a depressed skull fracture report LOC. Neurologic deficits may be present, depending on the extent of underlying brain tissue injury. A linear vault fracture puts the patient at an increased risk of intracranial hematoma.

A CT scan is indicated for any patients suspected of sustaining a depressed skull fracture and will ultimately be used to determine the depth of depression and to indicate the presence of any concurrent traumatic intracranial lesions.

Outcome after a depressed skull fracture is based on the severity of the trauma to the underlying area of brain.


Pediatric cases of depressed skull fracture typically occur in the frontal or parietal regions of the skull. Statistically one-third of pediatric depressed skull fractures are closed or simple fractures. These usually present after an accident at home and occur in younger children as a result of the malleable nature of the skull. Open or compound fractures typically present in children as a result of MVC. In children simple depressed skull fractures show no difference in outcome when comparing surgical vs. non-surgical approaches for treatment. Indications for surgery are listed below. “Ping-pong ball” fractures are typically only seen in newborns due to malleability of skull. Presents as a focal caving in area of the skull akin to a pushed in area on a ping-pong ball. Indications for surgery are listed below. As a reference no treatment is necessary if this type of fracture occurs in the temporoparietal region in the absence of underlying brain injury as the deformity is usually corrected as the skull grows.

Timing of surgery

Should be early as to avoid increase in risk of infection

Indications for Surgery

Open (Complex Fracture)

1.Surgery indicated for fractures where depression is greater than the thickness of the calvaria
2. Non-surgical management may be considered if
a. No evidence of dural penetration (CSF leak or pneumocephalus on CT)
b. No significant intracranial hematoma
c. Depression is greater than 1 cm
d. No frontal sinus involvement
e. No wound infection or contamination
f. No gross cosmetic deformity

Closed(Simple Fracture)

1.Can be managed with surgery or non-surgery


1.Definitive evidence of dural penetration
2. Persistent cosmetic defect in older children after swelling as subsided
3. Focal neurologic deficit related to fracture

Ping-pong ball

1. Radiographic evidence of intraparenchymal bone fragments
2. Associated neurologic deficit (rare)
3. Signs of increased intracranial pressure
4. Signs of CSF leak
5. Difficulty with long-term follow up


2.Greenberg, Mark S. "Depressed Skull Fractures.” Handbook of Neurosurgery. 7th ed. New York, NY: Thieme, 2010. 885-886
3.Biros, Michelle H., and William G. Heegaard. "Chapter 38, Head Injury." Rosen's Emergency Medicine: Concepts and Clinical Practice. By John A. Marx, Robert S. Hockberger, and Peter Rosen. Philadelphia, PA: Mosby Elsevier, 2006. 295-322.
4.Golfinos JG, Cooper P: “Skull fracture and traumatic cerebrospinafistulas.” In: Cooper P, Golfinos J, ed. Head Injury, 4th ed. New York: McGraw-Hill; 2000:155-174.
5.Rengachary, Setti S., and Richard G. Ellenbogen. Principles of Neurosurgery. 2nd ed. Edinburgh: Elsevier Mosby, 2005. Pg 303
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