Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Depressed Skull Fracture Elevation

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [closed/open (compound)] depressed skull fracture of the [location] [± underlying dural/parenchymal injury] following [mechanism] planned for craniotomy for elevation and debridement.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

External sources — operative figures/atlases are copyrighted (linked, not copied). See media-sources.md for licensing.

Operative technique & approach

Imaging

Open-access figures

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Depressed Skull Fracture Elevation — FIG. 1. FIG. 1.. Case 1.Preoperative coronal bone (A) and brain (B) window noncontrast CT scans, axial bone (C) and brain (D) window noncontrast CT scans, and a 3D reconstruction (E) showing a depressed… Source: Use of a percutaneous bone fiducial screw for elevating simple closed depressed skull fractures: illustrative cases — Journal of Neurosurgery: Case Lessons 2024; CC BY-NC-ND.

Depressed Skull Fracture Elevation — FIG. 2. FIG. 2.. Case 1. A: The bone fiducial used: total length 1.5 cm, screwhead length 3 mm. B: Percutaneous placement of the bone fiducial at the point of maximal fracture depression. C: Elevation of… Source: Use of a percutaneous bone fiducial screw for elevating simple closed depressed skull fractures: illustrative cases — Journal of Neurosurgery: Case Lessons 2024; CC BY-NC-ND.

Depressed Skull Fracture Elevation — FIG. 3. FIG. 3.. Case 2.Images showing the elevation of a right parietal depressed skull fracture. Preoperative coronal bone (A) and brain (B) window noncontrast CT scans. Preoperative axial bone (C) and… Source: Use of a percutaneous bone fiducial screw for elevating simple closed depressed skull fractures: illustrative cases — Journal of Neurosurgery: Case Lessons 2024; CC BY-NC-ND.

Depressed Skull Fracture Elevation — FIGURE 2. FIGURE 2.. Surgical care pathways of participants with EDHs, by presence of concomitant acute subdural hematomas and/or IPHs on the first scan. A, Participants with isolated EDHs (n = 133). Most of… Source: Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study — Neurosurgery 2024; CC BY.

Depressed Skull Fracture Elevation — FIG. 1. FIG. 1.. A: Coronal CT shows depressed skull fracture fragment at midline. B: Sagittal CT venogram (CTV) shows occlusion of SSS anterior to fracture. C: Coronal CTV shows thrombus in sagittal… Source: Pediatric skull fracture with injury and thrombosis of the superior sagittal sinus: illustrative case — Journal of Neurosurgery: Case Lessons 2022; CC BY-NC-ND.

Depressed Skull Fracture Elevation — FIG. 2. FIG. 2.. MRV at follow-up showing resolution of sagittal sinus thrombosis. Source: Pediatric skull fracture with injury and thrombosis of the superior sagittal sinus: illustrative case — Journal of Neurosurgery: Case Lessons 2022; CC BY-NC-ND.

Depressed Skull Fracture Elevation — Figure 4. Figure 4.. (a) Depressed skull fracture and subsequent (superior sagittal sinus) SSS thrombosis caused by a hammer blow – (i) midsagittal reconstruction on day 2 with increasing headaches… Source: Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure — Journal of Cerebral Blood Flow & Metabolism 2016; CC BY-NC.

Depressed Skull Fracture Elevation — Figure 7. Figure 7.. Diagram demonstrating that relative venous outflow restriction can occur intracranially (with compression/obstruction (e.g. with thrombus or fractures) of isolated or diffuse venous… Source: Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure — Journal of Cerebral Blood Flow & Metabolism 2016; CC BY-NC.

Depressed Skull Fracture Elevation — Figure 1 Figure 1. Illustrative case – Lateral head photograph showing the depressed skull fracture (black arrow). Source: Closed Depressed Skull Fracture in Childhood Reduced with Suction Cup Vacuum Method: Case Report and a Systematic Literature Review — Cureus 2019; CC BY.

Depressed Skull Fracture Elevation — Figure 2 Figure 2. Illustrative case – Anteroposterior X-ray showing the bone deformity (white arrow). Source: Closed Depressed Skull Fracture in Childhood Reduced with Suction Cup Vacuum Method: Case Report and a Systematic Literature Review — Cureus 2019; CC BY.

History of Present Illness

Past Medical History

Imaging Review

CT Head — Bone Windows

CT Head — Brain Windows

CT Venogram (if fracture overlies a venous sinus)

Criteria for Surgical Intervention

Labs

Neurological Examination

Glasgow Coma Scale (GCS)

Focal Deficits (depend on location of depression)

Open vs Closed Fracture Assessment

Cranial Nerve Exam

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Open vs Closed Fracture Management Differences

Feature Open (compound) Closed
Timing Urgent (within 24h; earlier if contaminated) Semi-elective if stable
Antibiotics Broad-spectrum empiric + wound culture Standard surgical prophylaxis only
Debridement Required — excise devitalized scalp, remove debris Minimal
Bone fragments Discard if grossly contaminated or comminuted Replace if single fragment, clean edges
Dural repair Mandatory watertight closure if violated Repair if torn
Infection risk High (meningitis, abscess, osteomyelitis) Low
Cranioplasty Often delayed (6-12 months) if bone discarded Primary replacement typical

Antibiotic Protocol for Open Fractures

Timing of Surgery

Position

Key Surgical Steps

  1. Wound debridement (open fractures): Excise devitalized scalp edges (minimal — preserve vascularity), remove gross contamination, hair, foreign material; extend laceration if needed for adequate exposure
  2. Incision planning: Use existing laceration if adequate; otherwise curvilinear incision centered on the fracture with adequate margins in normal bone
  3. Craniotomy / burr hole placement: Place burr hole(s) in normal bone adjacent to the depressed segment — never through the fractured fragments; use craniotome to create a rim of craniotomy around the depressed area
  4. Elevation of depressed fragments: Using a periosteal elevator or Penfield dissector, carefully lever fragments upward from the adjacent craniotomy edge; avoid plunging — the dura and cortex are directly beneath; apply upward force only, never push inward
  5. Dural inspection: Examine dura under the entire depressed area; document intact vs lacerated
  6. Dural repair (if lacerated): Primary repair with 4-0 Nurolon if edges approximate; dural substitute graft (DuraGen, AlloDerm, pericranium) if defect too large; watertight closure mandatory; apply dural sealant (DuraSeal)
  7. Evacuate underlying hematoma / foreign material: Remove epidural or subdural clot if present; debride contused brain only if necrotic/pulped; remove indriven bone fragments, hair, debris under direct visualization
  8. Copious irrigation: Normal saline (open injuries — minimum 1-2 L)
  9. Fragment management:
    • Clean, single fragments (closed or minimally contaminated open): Replace and fix with titanium microplates/screws
    • Contaminated or comminuted fragments: Discard; plan delayed cranioplasty
    • Fragments over a venous sinus: May leave in place if sinus intact and removal risks hemorrhage
  10. Frontal sinus involvement: If posterior wall fractured — cranialization (strip mucosa, plug nasofrontal duct with muscle/bone) or obliteration
  11. Cranioplasty options for bone loss: Titanium mesh (immediate if clean), custom implant (PEEK, titanium — delayed), methylmethacrylate, autologous split calvarial graft; delayed reconstruction preferred if infection concern
  12. Sinus bleeding: Control with Gelfoam, Surgicel, packing, or repair; may leave fragment over patent sinus if removal risks exsanguination
  13. Closure: Galea with 3-0 Vicryl, skin with staples or nylon; subgaleal drain if large dead space; do not close contaminated wounds under tension

Critical Anatomy & Structures at Risk

  1. Dura and underlying cortex — laceration, contusion, indriven bone fragments
  2. Dural venous sinuses (superior sagittal, transverse, sigmoid) — major hemorrhage if fragment elevated off sinus
  3. Frontal sinus (anterior fractures) — mucocele, ascending infection if not addressed
  4. Middle meningeal artery — may be lacerated by fracture; epidural hematoma source
  5. Cortical veins — at risk during fragment elevation and dural repair
  6. Eloquent cortex — motor strip, language areas (location-dependent)

Equipment

Anesthesia

Potential Complications

  1. Infection (open injuries) — meningitis, brain abscess, osteomyelitis, wound infection; debridement, antibiotics, discard contaminated bone
  2. Venous sinus hemorrhage — torrential bleeding if fragment elevated off sinus; have blood products, hemostatic agents, and packing ready
  3. Sinus thrombosis — can occur from sinus compression or surgical manipulation
  4. Seizures — cortical injury/irritation; prophylaxis indicated
  5. CSF leak — inadequate dural repair; may require re-exploration or lumbar drain
  6. Cosmetic deformity — inadequate elevation or bone loss requiring delayed cranioplasty
  7. Frontal sinus mucocele — late complication if sinus not properly cranialized
  8. Growing skull fracture (pediatric) — dural tear + growing brain herniates through fracture; presents months later with enlarging palpable defect; requires dural repair and cranioplasty

Operative Note Template

Preoperative Diagnosis: [Open (compound)/Closed] depressed skull fracture of the [left/right] [frontal/parietal/temporal/occipital] region [± dural laceration / underlying hematoma / frontal sinus involvement]

Postoperative Diagnosis: Same [or updated findings]

Procedure: Craniotomy for elevation of depressed skull fracture [with debridement / dural repair / cranioplasty / frontal sinus cranialization]

Surgeon: Assistant: Anesthesia: General endotracheal anesthesia

EBL: Fluids: Specimens: [Bone fragments / wound culture / none] Drains: [Subgaleal drain / none] Complications: None Implants: [Titanium microplates and screws / titanium mesh / dural graft / none]

Indications: The patient is a [age]yo [M/F] who presented following [mechanism] with [scalp laceration and palpable depressed fracture / focal deficit / GCS ]. CT head demonstrated a [open/closed] depressed skull fracture of the [left/right] [location], depressed [ mm / greater than one full table thickness] beyond the inner table [with underlying contusion / epidural hematoma / pneumocephalus / frontal sinus involvement]. [Open compound fracture with contamination risk.] Given [depression depth / open fracture / dural violation / deficit / cosmetic deformity], surgical elevation and debridement were indicated. Risks (infection, hemorrhage, seizure, CSF leak, cranioplasty) discussed with [patient / family]; consent obtained. [Anticoagulation reversed with ___.] Antibiotics, tetanus, and seizure prophylaxis administered.

Description of Procedure: After informed consent was verified and the surgical site was confirmed, the patient was brought to the operating room. General endotracheal anesthesia was induced [via rapid sequence induction]. An arterial line, Foley catheter, and two large-bore IVs were placed. Preoperative cefazolin [2g IV] [and metronidazole 500 mg IV], levetiracetam [1000 mg IV], and [tetanus prophylaxis] were administered.

The patient was positioned [supine/lateral] with the head rotated to place the [location] fracture site uppermost. The head was secured in a [Mayfield skull clamp / horseshoe headrest]. All pressure points were padded. A time-out was performed. The [left/right] [region] was prepped and draped in standard sterile fashion.

[The scalp laceration was debrided — devitalized wound edges excised, gross contamination removed, and wound culture obtained.] [For closed fractures: A curvilinear scalp incision was made centered over the fracture.] Burr holes were placed in normal bone adjacent to the depressed segment. A craniotomy was performed with the craniotome, creating a rim of bone removal around the depressed area. The depressed fragment(s) were carefully elevated using a periosteal elevator, applying upward force only. [The fragment was a single piece / multiple comminuted fragments were encountered.]

The dura was inspected under the entire depressed area and found to be [intact / lacerated]. [A __ cm dural laceration was repaired primarily with 4-0 Nurolon / repaired with a [pericranial / DuraGen] graft secured with 4-0 Nurolon sutures. Dural sealant was applied.] [The underlying cortex was intact / an underlying contusion was debrided / an epidural hematoma of __ mL was evacuated.] The field was copiously irrigated with normal saline.

[The bone fragment was clean and replaced in anatomic position with titanium microplates and screws. / The fragments were contaminated and comminuted — discarded; delayed cranioplasty planned. / Titanium mesh was contoured and secured over the defect.] [The frontal sinus mucosa was stripped, nasofrontal duct plugged, and sinus cranialized.] [A subgaleal drain was placed.] The galea was closed with 3-0 Vicryl, skin with [staples / nylon]. A sterile dressing was applied.

The patient was awakened, extubated [/ remained intubated], and found to be [following commands / GCS ___]. Transferred to the [ICU / floor] in stable condition.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Depressed Skull Fracture Elevation:

Common Pimp Questions

Use these to pressure-test preparation for Depressed Skull Fracture Elevation:

  1. What is the life-threatening mass-effect problem and what is the operative endpoint?
  2. What anticoagulant/antiplatelet reversal and blood-product plan is required before incision?
  3. What exposure gives rapid control while preserving options for expansion?
  4. What ICP, seizure, sodium, ventilation, and blood-pressure targets matter immediately postop?
  5. What injury pattern or associated lesion would change the incision, bone flap, or disposition?

Attending Preference Variables

Items that commonly vary by surgeon or institution: