Posterior cranial fossa depressed fracture.

Sir,

Depressed skull fractures result from high-energy direct blows to a small surface area of the skull by a blunt object.[1] A 9-year-old male child present with the history of being hit by stone on the back of his head. He had history of loss of consciousness for 10 min and multiple episodes of vomiting. On examination, the child was drowsy, opening eyes to call and obeying commands. Pupils were bilateral, equal, and reacting to light. There were no focal motor deficits. Computer tomography (CT) scan of the brain showed a significant depressed fracture of the right occipital bone [Figure 1] and no hydrocephalus. The patient underwent exploration of the wound and removal of the loose bone fragments. In addition, he was managed with anti-edema measures, recovered completely, and was doing well at follow-up. Because of multiple layers of muscle and soft tissue covering the suboccipital region, depressed fractures in adults are rare;[12] however, due to the thin skull and relatively less soft tissue in the sub-occipital region, these lesions have been reported more frequently.[3] Non-depressed occipital bone fractures are commoner and majority of them do not require any surgical intervention.[4] However, as the posterior fossa is a relatively small and crowded space and any lesion reducing the volume can elevate the intra-cavitary pressure leading to fourth ventricular compression and hydrocephalus,[456] a mechanism may be responsible for brain stem dysfunction in cases of closed depressed fracture of the posterior fossa.[127] As seen in the present case, early surgical intervention for closed fracture in the posterior fossa with significant depression, particularly when the patient is in altered sensorium with low Glasgow coma scale, is associated with good outcome.[7]

Figure 1

Plain computer tomography posterior fossa showing significant right occipital comminuted depressed fracture