Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

closed nondepressed fracture

1st line – observation and monitoring

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ACUTE
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closed nondepressed fracture
1st line – 

observation and monitoring

Treatment of closed nondepressed fractures is primarily conservative. Conservative treatment consists of observation to rule out any ongoing complications such as cerebrospinal fluid (CSF) leak, seizure, or infection.

Medical interventions such as anticonvulsant and antibiotic prophylaxis are not routinely given to patients with isolated skull fractures. There is little definitive evidence of benefit for antibiotics in decreasing the risk of subsequent meningitis or other infections 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 fracture

1st line – observation and monitoring

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ACUTE
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closed depressed fracture
1st line – 

observation and monitoring

Treatment of closed depressed fractures is primarily conservative; operative elevation and repair offer little benefit in terms of reduction in risk of seizure, infection, or neurologic deficit.

Conservative treatment consists of observation to rule out any ongoing complications such as cerebrospinal fluid (CSF) leak, seizure, or infection. Medical interventions such as anticonvulsant and antibiotic prophylaxis are not routinely given to patients with isolated skull fractures. There is little definitive evidence of benefit for antibiotics in decreasing the risk of subsequent meningitis or other infections 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

Consider – prophylactic anticonvulsant therapy

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ACUTE
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closed depressed fracture
Consider – 

prophylactic anticonvulsant therapy

Treatment recommended for SOME patients in selected patient group

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 the short-term 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.

Primary options

phenytoin: 1000 mg intravenously/orally as a loading dose, followed by 300 mg once daily for 7 days post-injury, titrate dose according to response

OR

levetiracetam: 500-1000 mg orally twice daily for 7 days post-injury

Consider – dural repair and cranioplasty

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ACUTE
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closed depressed fracture
Consider – 

dural repair and cranioplasty

Treatment recommended for SOME patients in selected patient group

Operative elevation and repair of dura and cranioplasty should be considered for any patient with a depressed fracture >1 cm, gross cosmetic deformity, evidence of dural tear, or an associated operable intracranial lesion.[5][11][45][68][69][70][71]

open fracture

1st line – observation and monitoring

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ACUTE
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open fracture
1st line – 

observation and monitoring

Evidence suggests that open skull fractures be treated conservatively if there is no intracranial hemorrhage, cerebrospinal fluid (CSF) leak, or gross contamination.[69] Conservative treatment consists of observation to rule out any ongoing complications, such as CSF leak, seizure, or infection.

Medical interventions such as anticonvulsant and antibiotic prophylaxis are not routinely given to patients with isolated skull fractures. There is little definitive evidence of benefit for antibiotics in decreasing the risk of subsequent meningitis or other infections 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

Consider – prophylactic anticonvulsant therapy

Back
ACUTE
|
open fracture
Consider – 

prophylactic anticonvulsant therapy

Treatment recommended for SOME patients in selected patient group

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 good evidence to support the short-term 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.

Primary options

phenytoin: 1000 mg intravenously/orally as a loading dose, followed by 300 mg once daily for 7 days post-injury, titrate dose according to response

OR

levetiracetam: 500-1000 mg orally twice daily for 7 days post-injury

Consider – prompt debridement + dural repair and cranioplasty

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ACUTE
|
open fracture
Consider – 

prompt debridement + dural repair and cranioplasty

Treatment recommended for SOME patients in selected patient group

Operative repair is recommended in any patient who has an open fracture with intracranial hemorrhage, cerebrospinal fluid leak, gross contamination, or with gross cosmetic deformity.[11][69][70][71] 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]

ONGOING

persistent cranial nerve injury or CSF leakage

1st line – endoscopic intranasal surgical repair

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ONGOING
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persistent cranial nerve injury or CSF leakage
1st line – 

endoscopic intranasal surgical repair

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 cerebrospinal fluid (CSF) leakage.[73][74] This is most commonly seen with basilar fractures. 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;​​​ 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] 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

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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