Approach

Treatment of skull fractures is primarily conservative.

Most nondepressed (linear) fractures, including basilar skull fractures, are treated conservatively as long as: there is no suspicion or evidence of intracranial pathology; neurologic status is normal; and there is no evidence of cranial nerve damage or cerebrospinal fluid (CSF) leak.

Conservative treatment consists of observation to rule out any ongoing complications such as CSF leak, seizure, or infection. Evidence from a single tertiary center suggests that implementation of evidence-based guidance can reduce hospitalization rates for neurologically intact children with isolated skull fracture without an increase in readmissions.[60]

A depressed fracture, an open fracture, or a fracture with associated intracranial pathology, cranial nerve deficit, or CSF leak (most likely a basilar fracture) may require surgical intervention. Children rarely require surgery; however, those with frontal skull fractures may be more likely to require operative repair.[61]

Medical interventions such as anticonvulsant and antibiotic prophylaxis are not routinely given for isolated skull fractures. Anticonvulsants, when given, are usually on the recommendation of a neurosurgeon for associated underlying intracranial injury such as subarachnoid hemorrhage or subdural/epidural hemorrhage or intraparenchymal hemorrhage, to prevent early traumatic brain injury-associated seizures, and are given for the first 7 days post-injury. There are no data to support prolonged antiseizure prophylaxis in the absence of documented seizures post-injury.

There is little definitive evidence of a clear benefit for antibiotics in decreasing the risk of subsequent meningitis or other infections in fractures, with or without CSF leak.[62][63][64][65] Pneumococcal vaccination is recommended for patients with a basilar skull fracture and a CSF leak.[66][67] Specific recommendations exist for pediatric and adult patients with CSF leak. CDC: recommended child and adolescent immunization schedule by medical condition, United States Opens in new window CDC: recommended adult immunization schedule by medical condition and other indications, United States Opens in new window

Closed depressed skull fractures

The first-line treatment still remains conservative management, because operative elevation and repair offer little benefit in terms of reduction in risk of seizure, infection, or neurologic deficit. Operative elevation and repair of dura and cranioplasty should be considered for any patient with:[5][11][45][68][69][70][71]

  • A depression >1 cm

  • Gross cosmetic deformity

  • Evidence of dural tear

  • An associated operable intracranial lesion.

Open skull fracture

Evidence suggests that open skull fractures should also be treated conservatively if there is no intracranial hemorrhage, CSF leak, or gross contamination.[69] Operative repair is recommended in any patient not meeting the above criteria, and in those with gross cosmetic deformity.[11][70][71]​ When required, surgery should be considered earlier rather than later, as treatment delay increases the risk of infectious complications. Operative repair should concentrate on debridement of devitalized tissues, evacuation of any surgical intracranial lesions, dural closure, and cranioplasty. Bone fragment replacement does not appear to increase the risk of infectious complications.​[11][70][71][72]

Single-stage procedures are now routinely performed. Grossly contaminated open skull fractures should be followed up in 2 to 3 months with computed tomography scans to rule out intracranial infection.[5][45][71]

Basilar skull fractures with evidence of cranial nerve injury or persistent CSF leakage

Operative repair may be required if there is evidence of cranial nerve injury (e.g., hearing loss persisting for >3 months, facial paralysis) or persistent CSF leakage.[73][74]​ However, there is little evidence that surgical treatment of facial paralysis is superior to conservative management.[75] CSF leakage may initially be treated with lumbar drainage;[76][77]​ if the CSF leakage is persistent, primary surgical treatment is endoscopic intranasal surgical repair, which has a better outcome and lower morbidity than craniotomy.[55][74][76][77][78]​​ The most common complication of intranasal surgery is anosmia.[55][76]

Posttraumatic seizures

Posttraumatic seizures (PTS) are common following severe traumatic brain injury, and risk of PTS is significantly increased even following mild and moderate brain injury.[11][79][80] There is evidence to support short-term, prophylactic use of anti-epileptic drugs (AED), particularly phenytoin.[79][81][82] [ Cochrane Clinical Answers logo ] Levetiracetam may also be used. However, AEDs have not been shown to have any effect on decreasing the risk of late PTS (≥8 days) or posttraumatic epilepsy, and their use beyond the first week post-injury is not supported or recommended.[11][79][80][81][82]

Outside of severe depressed skull fractures, there is no data supporting the use of AEDs for either early or late PTS prevention in isolated skull fractures in the absence of underlying brain injury. For patients who continue to have seizures and carry the diagnosis of posttraumatic epilepsy, treatment of seizures is similar to epilepsy of nontraumatic origin.[11][81][82]

Prophylactic anticonvulsant therapy would therefore be considered and given only for open depressed skull fractures or fractures associated with an underlying brain injury. It is not indicated or recommended for simple isolated skull fractures.

If a seizure occurs, it can be therapeutically treated - as any nontraumatic seizure would be - with benzodiazepines and subsequent anti-epileptic medication.

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