Midline Depressed Fractures of the Skull

Abstract

Objective: To evaluate the results of management of middle depressed fracture skull.
Depressed skull fracture is a common neuro-traumatic emergency. The commonest causes in our society are fall from height and road traffic accident. The frequency of depressed fractures is that it occurs in 75% in fronto-parietal region, 10%1 in temporal region, while in occipital is 5% and in others is 10%. In time surgical manage-ment gives excellent results and leads to minimize the sequel of this condition. Most of the causes can be pre-vented just by adopting preventive measures. The condition can be treated in periphery hospital as well, if trained personals are available. Midline depress fracture are rare. Depressed fracture over venous sinuses requires special handling. Surgical elevation involves massive blood loss. Most of them are treated conservatively.
Material and Methods: We conducted a 4 years study in the department of Neurosurgery, Lahore General Hospital from 2009 to 2013.
Results: We included 30 patients of mid line depressed fractures in which 20 were treated by surgical elevation and 10 by conservative management. Follow of 3 months to 1 year. In a total of 3750 patients who presented in the emergency department, 540 (14.4%) patients were operated for depressed skull fractures in which midline depressed fractures were 20 (4%). There were 20 patients in whom the anterior 1/3rd of superior sagittal sinus was involved, in 6 patients the middle 1/3rd of superior sagittal sinus was involved while in only 4 patients the posterior 1/3rd of superior sagittal sinus was involved. We paid special attention to these midline fractures involv-ing the venous sinuses. In 4 of our patient we encountered severe blood loss as the depressed fragment was being plugged in sinus tear. In 12 patients we carefully elevated the depressed fractures and gained control over the venous sinus as soon as possible with the help of spongiston and packing technique. In 8 patients the fracture site was not contaminated with foreign material, there was no cosmetic issue and no focal deficit found, they were managed by scalp debridement along thorough irrigation and primary closure. Out of operated 20 patients only two patients presented with mild wound infection but it settled down with proper antibiotic therapy. In the con-servative group out of 10 patients 2 patients developed epileptic seizure after 3 months and 7 months of trauma and they were managed by giving antiepileptic drugs.
Conclusion: In our study we concluded that elevation of depressed fracture over SSS can be attempted whenever patients clinical condition warrant. Elevation of the bone along with debridement of the wound resulted in rapid and dramatic resolution of signs and symptoms of raised ICP and venous hypertension. The study also showed an improvement in the cosmesis and reduction in the overall wound infection rate.