Depressed Skull Fracture

Depressed skull fractures typically occur when a large force is applied over a small area. They are classified as open if the skin above them is lacerated. Abrasions, contusions, and hematomas may also be present over the fracture site.
The patient’s mental status is dependent upon the degree of underlying brain injury. Direct trauma can cause abrasions, contusions, hematomas, and lacerations without an underlying depressed skull fracture.  Evidence of other injuries such as a basilar fracture, facial fractures, or cervical spinal injuries may also be present.

                                            CT demonstrating depressed skull fracture. 

Management: Explore all scalp lacerations to exclude a depressed fracture. CT should be performed in all suspected depressed skull fractures to determine the extent of underlying brain injury.

• Depressed skull fractures require immediate neurosurgical consultation. 
• Treat open fractures with antibiotics and tetanus prophylaxis as indicated. 
• The decision to observe or operate immediately is made by the neurosurgeon. 

Children below 2 years of age with skull fractures can develop leptomeningeal cysts, which are extrusion of CSF or brain through dural defects. For this reason, children below age 2 with skull fractures require close follow-up or admission.

Ping pong ball skull fractures can occur in new borns from a forceps delivery or from compression by mother’s sacral promontory during delivery.

Ping Pong Ball Skull Fracture.  Akin to the greenstick fracture, a ping pong ball fracture occurs when a newborn or infant’s relatively soft skull is indented by the corner of a table or similar object without causing a frank break in the bone.

                                                CT demonstrates the ping pong ball effect.