0:01

It has often been said that the presence of fractures

0:05

is not as important as the presence of underlying

0:10

brain parenchymal or extra-axial collections.

0:15

With regard to the patient's prognosis, and

0:17

by and large, neurosurgeons do not do very much

0:21

about routine non-depressed, non-comminuted fractures

0:27

of the skull.

0:28

However, when that fracture is open, in other

0:31

words, when there is an opening from the skin

0:34

surface to the fracture and then to the intracranial

0:37

contents, then they will consider doing surgery

0:41

because of the high risk of potential infection

0:45

from the skin surface, which is usually dirty

0:48

from the trauma, into the meningeal space

0:52

through the fracture site. So open

0:55

fractures and fractures that are depressed

0:58

greater than one thickness of the skull.

1:01

So let's say that the skull is 10 millimeters

1:03

thick. If the fracture is depressed inward by

1:07

greater than that 10-millimeter thickness of

1:09

the skull and without overlap of the skull,

1:12

then they're more likely to go into

1:15

correct the depressed skull fracture.

1:18

Simple fractures that are not greater than one thickness

1:21

depressed inward are ones where they may do observation

1:26

and maybe even prophylactic antibiotics if they're

1:30

concerned about the possibility of an infection.

1:34

Here is a CT scan, which shows a dramatic trauma

1:39

to this patient's right side of the calvarium.

1:42

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

1:44

we see is that these fracture fragments, comminuted

1:48

fracture, are depressed greater than one width of the

1:54

normal calvarium.

1:55

So were they to just overlap just a

1:58

little bit here and not depressed, greater

2:01

than full thickness of the calvarium,

2:03

these might be treated with observation

2:06

rather than surgery. But because of their

2:09

inward depression, greater than one thickness,

2:12

this is an indication for surgery.

2:14

This is also an indication for surgery.

2:16

You note that

2:17

in this example, there is an

2:19

open wound to the skin surface.

2:22

So this is a laceration leading to the fracture.

2:25

And in fact, you even see some intracranial air

2:30

here, suggesting that there is a communication from

2:33

the outside world to the intracranial contents.

2:36

This is an open fracture that the surgeons

2:39

would correct and also treat locally

2:42

with, you know, appropriate antibiotics.

2:44

In this instance, we are not actually

2:47

seeing anything intraparenchymal with this

2:51

compound, comminuted, depressed fracture.

2:55

The brain underlying it doesn't look that bad,

2:58

so this would just be surgery to address the

3:01

fracture rather than, for example, draining a

3:03

hematoma or an epidural or a subdural hematoma.

3:09

So depressed skull fractures where it's

3:12

depressed inward but not greater than one

3:14

skull thickness may be treated non-operatively

3:18

if there's no evidence of dural penetration and

3:21

there's depression that's not very significant.