Authors of section

Authors

S Fusetti, B Hammer, R Kellman, C Matula, EB Strong, A Di Ieva

General Editor

Daniel Buchbinder

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Treatment of depressed cranial vault fractures

1. Approach

For this procedure the coronal approach or the lateral skull base approach is normally used, depending on fracture location. However, if present, lacerations can be used to directly access fracture sites for fracture managment.

Principles

2. Treatment of depressed cranial vault fractures

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.

Treatment of depressed cranial vault fractures

Use a dissector to carefully dissect the dura free.

Treatment of depressed cranial vault fractures

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.

Treatment of depressed cranial vault fractures

A craniotomy is performed by linking the burr holes. Bone fragments are then removed.

Treatment of depressed cranial vault fractures

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.

Treatment of depressed cranial vault fractures

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.

Treatment of depressed cranial vault fractures

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.

Treatment of depressed cranial vault fractures

Suspension sutures of the dura to the bony margins will minimize the risk of postoperative epidural hematoma.

Treatment of depressed cranial vault fractures

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.

Treatment of depressed cranial vault fractures

For further cranioplasty techniques click here.

3. Aftercare following open management of cranial vault fractures

General postoperative care

  • Intensive care 24 hours
  • Hospitalization 5-8 days (to rule out reoccurrence of CSF leak)
  • The use of broad-spectrum antibiotics during and after the procedure for the next 5-7 days is recommended.
  • Radiologic control examinations are performed routinely the next day after leaving the intensive care unit.
  • Patient follow-up after discharge. The patient is seen 4 weeks after, and if necessary, for the long-term follow-up a year postoperatively.