In order to elevate depressed cranial vault fractures make one or more burr holes outside the fractured area. Save the fragments and bone dust produced by drilling in saline for later reconstruction of the burr hole.
Use a dissector to carefully dissect the dura free.
In some cases, after making a burr hole and inserting an elevator, the bony fragments can be lifted up and the fracture reduced. If successful, no additional craniotomy is necessary.
A craniotomy is performed by linking the burr holes. Bone fragments are then removed.
The fractured segments are removed taking great care to avoid extending dural tears. If fragments have penetrated the brain, special care has to be taken during removal.
If the fragments are interlocked, a routine craniotomy is performed including the depressed fracture. The bone flap is then turned up-side down and the fragments are reduced by using a mallet. The bone flap is replaced and fixed.
If there is a dural laceration, it is highly recommended to open the dura, especially in case of subdural bleeding. After the evacuation of the subdural hematoma, a duraplasty is performed.
Suspension sutures of the dura to the bony margins will minimize the risk of postoperative epidural hematoma.
Reposition the bone flap and secure it to the surrounding bone with rigid fixation. A minimum of three fixation points assures stability. In some cases, the bone fragments can be used to reconstruct the bone flap using plates and screw. Bone dust or other materials can be used to fill the gaps between the fracture lines.