Management of massive calvarial exposure in young children

Although small areas of exposed calvaria commonly occur in seriously burned children, these wounds are generally straightforward management problems. In contrast, management of the nearly completely exposed calvaria is an extraordinarily difficult problem--but is fortunately rare. Over the past 15 years, we have treated 119 children with full-thickness calvarial wounds requiring grafting. Four (3.4%) of these patients (average age, 2.9 years; range, 22 months to 5.5 years) had massive exposure of nonviable calvaria, defined as 75% or more of the surface area of the calvaria. These wounds were open an average of 28 months (range, 6 to 45 months). We have concluded that optimal management involves staged debridement of the desiccated outer table with a high-speed drill, taking appropriate precautions to avoid air embolism or inadvertent dural injury in the area of sutures or fontanelles. The resulting wounds quickly granulate and can be autografted.