NONSURGICAL TREATMENT OF COMPOUND DEPRESSED SKULL FRACTURES

Classical treatment of compound depressed skull fractures includes deb ridement and closure of all scalp wounds to minimize the risk of delay ed intracranial infection. In selected situations, a nonsurgical appro ach may prove to be equally safe. Over a 33-month period, we evaluated 1075 patients for head trauma. There were 63 patients with non-missil e, compound depressed skull fractures (9 of these 63 patients have bee n excluded for deaths that occurred within 4 days of admission). Patie nts with significant intracranial hematomas or dural violations over t he convexity of the brain underwent formal surgical therapy. Surgical therapy was performed on 28 patients (52%; age 33 +/- 3 years; ISS 24 +/- 2) and it consisted of craniotomy with debridement, elevation of d epressed fragments, repair of dural tears, and evacuation of hematomas . Nonsurgical treatment was used if there was no evidence of violation of the dura mater and of significant intracranial hematoma. If the fo llowing criteria were satisfied, then the nonsurgical approach was emp loyed: no evidence of exposed brain or a cerebrospinal fluid leak, no- pneumocephalus related to the fracture, no depressed fragments of bone more than 1 cm below the inner table of the skull, and no gross wound contamination. Nonsurgical therapy was used on 26 patients (48%; age 34 +/- 3 years; ISS 19 +/- 2) and it consisted of wound irrigation, de bridement, and closure. In all 54 patients of both subsets of patients , intravenous antibiotics were administered for 5 to 7 days. After two additional days of observation, off antibiotics, the patients were di scharged. There were no infectious complications related to the centra l nervous system. Patients with open skull fractures who do not demons trate evidence, either clinically or radiographically, of violation of the dura mater or of a significant underlying brain injury may be tre ated with local wound care and intravenous antibiotics without an incr eased risk of a subsequent central nervous system infection.