Management of depressed skull fractures. Selective conservative management of nonmissile injuries

The management of 319 cases with nonmissible depressed skull fractures is discussed. The majority of these injuries (75%) resulted from assaults and more than 90% were compound fractures. Of these, 35 cases were excluded from the series; these were patients who died before investigation or treatment could be instituted, or whose major injury was an intracranial hematoma or extensive traumatic hemorrhagic necrosis rather than a depressed fracture with underlying localized contusion. In the remaining 284 cases a comparison is made between the outcome in 124 (44%) patients treated by a conventional surgical method and 160 (56%) selected patients whose wound was only inspected, cleaned, and sutured in the emergency room. The nonsurgical group included 21 (9%) patients with simple depressed fractures and also patients without severe wound contamination, established infection, severe comminution of the fracture, or brain or cerebrospinal fluid in the wound. The results of management were assessed in relation to septic complications, the outcome of focal neurological abnormalities, and fatal complications. The group treated conservatively compared favorably with the surgical cases and also with previously reported series. The obvious bias in favor of the conservative group is admitted; however, it is clear that the majority of simple fractures and some compound depressed skull fractures can be managed safely without major surgical intervention. Socioeconomic implications are discussed.