Compound elevated skull fracture: Should we incorporate in skull fracture classification?

In majority of the cases, a depressed fracture is characterized by in driven fractured bone fragments. In contrast to this, in cases of “elevated skull fracture” due to tangential direction of the mechanical force, the bone fragment is elevated above the level of the intact skull.[12345] A 61-year-old gentleman presented with the history of stumble hit against the rail coach door. He was unconscious since the time of injury. There was no history of loss of seizures; vomiting; and ear, nasal, or oral bleed. There was an open wound from which he was profusely bleeding and brain matter was coming out. On examination, the pulse rate was 110/min. The patient was in altered sensorium and he was intubated to secure the airway. Glasgow Coma Scale (GCS) was E2V2M5. Pupils were bilateral equal and reacting to light. The patient was moving all four limbs equally. Local examination revealed a large scalp laceration with active bleeding and the brain matter was coming out from the wound. After hemodynamic stabilization, the patient underwent plain computed tomography (CT) brain with bone window. It showed compound elevated fracture of the frontal bone with underlying contusion and cerebral edema [Figures 1 and 2]. The patient was taken for emergency surgery. Scalp laceration was extended on either side and fracture bone flap was delivered from the wound [Figure 3]. The wound was irrigated thoroughly with normal saline. Contused brain tissue was evacuated and a lax duroplasty was performed. Bone flap was thoroughly washed with povidone–iodine and hydrogen peroxide, and was replaced. The patient was kept on elective ventilation. He was weaned off successfully and made a gradual recovery over a period of 10 days. He was discharged without neurological deficits.

Figure 1

(a-c) Axial CT plain images bone window showing the elevated skull fracture of frontal bone with few displaced fracture fragments and pneumocephalus. Axial CT scan plain images brain window (d-f) showing parafalcine hemorrhage, hemorrhagic, and nonhemorrhagic contusions in frontal lobe, extracalvarial herniation of the brain parenchyma, and air pockets. CT = Computed tomography

Figure 2

(a-c) Volume-rendered images of the skull showing the degree of elevation of the frontal bone in better detailc

Figure 3

(a and b) Intraoperative photographs showing herniation of necrotic brain through the defect and elevated bone fragment

The majority of these injuries are compound in nature and associated with injury to the scalp, bone, dura, and underlying brain parenchyma.[12345] Clinical features in these patients depend on the site, extent, and severity of the brain injury.[34678] Almost in all reported cases, the patient sustained compound wound (with herniation of the brain parenchyma and dural tear) and had maximum neurological deficits at the time of presentation[23478910] (except rare instance of delayed neurological deterioration).[6] CT brain plain with bone window is the primary investigation of choice to diagnose “elevated skull fractures”.[12345611] In addition, CT will also show the extent of the defect and any associated injury to the underlying brain parenchyma or any other intracranial hematomas.[12345611] In contrast to the depressed compound fractures, in patients with elevated compound fractures because of the tangential direction of the injury; a lesser force is transmitted to the skull and underlying brain and its coverings.[9] Probably because of this fact, the patient who sustain elevated compound fracture carries a better prognosis.[23569] The basic principles for the management of compound elevated skull fractures are same for any the other compound wound compound depressed skull fractures, that is, early recognition and prompt intervention (broad spectrum antibiotics, wound debridement, removal of loose bone fragments, and dural repair).[1234568111213] In patients with “elevated skull fracture”, compound nature of the wound makes it vulnerable to develop several complications (e. g., meningitis, abscess formation, or cerebrospinal fluid (CSF) fistula) and any delay in intervention can be catastrophic and can alter the prognosis.[23569] Like for any other compound injury, early recognition and adequate treatment of elevated skull fracture subgroup will prevent unnecessary complications (i. e., intracranial sepsis or CSF fistula), and thus will reduce the morbidity and mortality.[59] In literature there are several reports which describe “elevated skull fracture” as a unique entity, and based on their finding, it can be advocated that “elevated skull fracture” can be included in the traditional classification of skull fractures.[12345910]