INTRODUCTION

Depressed cranial fractures complicate up to 6% of head injuries in some series, and account for significant morbidity and mortality. Compound fractures account for up to 90% of these injuries, and are complicated with an infection rate of 1.9 to 10.6%, an average neurological morbidity of approximately 11%, an incidence of epilepsy of up to 15%, and a mortality rate ranging from 1.4 to 19%. Compound depressed calvarial fractures are depressed fractures with an overlying scalp laceration in continuity with the fracture site and disruption of the galea, and have conventionally been managed with debridement and surgical elevation. The concept of aggressive treatment of depressed cranial fractures stems from their association with infection and late epilepsy. Cosmetic deformity also plays a role in surgical decision making.¹

Traditionally, surgical management of compound depressed calvarial fractures entails elevation and removal of all bone fragments with delayed cranioplastic repair of the defect. Bone fragment removal is intended to reduce the potential for infection. However, bone fragment removal often necessitates another surgery to repair the resultant calvarial defect.²

The aim of this study is to assess the advantages and disadvantages of early one stage elevation, debridement and plastic repair of compound depressed fractures.

SUBJECTS AND METHODS

Retrospective analysis was done for 25 patients treated surgically after sustaining a compound depressed fracture due to a diverse of traumatic mechanisms. The patients were treated at Ain Shams university hospitals during the period from September 2007 to August 2010.

Pre-operative clinical assessment was performed with special attention to the timing and mode of trauma and the state of the wound in addition to evaluation of the neurological status of the patients. Pre-operative laboratory investigations included a complete blood picture, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) in addition to the routine investigations. All patients had a brain CT scan with bone window pre-operatively. Extended spectrum penicillin together with a third generation cephalosporin were given as prophylaxis to all patients once diagnosed according to the recommended doses.

All patients were operated upon as within the first 24 hours after the trauma except one patient that was operated upon after 36 hours after being stabilized. The degree of contamination was classified as mild when the wound appeared clean except for minimal contamination with hair, moderate when there was soiling of the wound and underlying tissues with foreign materials and severe when soiling extended beneath the bone and/or the dura. The severity of tissue losses was also stratified into: mild with simple wound gapping and no apparent loss, moderate when there was soft tissue and/or bone loss and severe when neural tissue loss was found with other tissues losses. The surgical technique adopted by the authors included debridement of devitalized soft tissues and elevation of the depressed bone in the usual manner. The extracted bone was soaked in diluted hydrogen peroxide solution (15%) for at least 15 minutes then washed with normal saline. The surgical field was also irrigated in the same sequence after control of bleeding and dural closure. Finally, primary repair using bone fragments kept in place with a non-absorbable suturing material or titanium miniplates was performed. In cases where extensive bone cominution was found titanium mesh was used.

Post-operative vital data and neurological condition were followed for at least the first 72 hours. During this period the patients continued on the same chemo prophylactic agents given pre-operatively. A follow up brain CT scan with bone window was done prior to discharge of the patient. Follow up of patients was done in outpatient clinic for the cosmetic and functional outcome and for any manifestations late infection.

Figure (1) shows the CT scans of a 19 years old male patient who sustained a blunt trauma with a stone in his forehead that resulted in a frontal compound depressed fracture extending to the anterior cranial fossa base repaired using miniplates and screws.

Figure (2) shows the CT scans of a 10 years old male patient who had a right parietal fracture due to falling from a height. The fracture was elevated and repaired by miniplates and screws.

Figure (3) shows the C T scans of a 26 years old male patient who had a right occipital fracture that was repaired using a mesh.

Figure (4) shows the CT scans images of a 19 years old male patient who had a left frontal compound depressed after being hit by a hard object. The fracture was repaired using non-absorbable prolene sutures.

Figure 1. Pre-operative (left), post-operative (middle) CT scan and post-operative 3 dimensional (left) images of the patient.

Figure 2. Pre-operative (A) CT scan image, intra-operative photographs (B, C) and post-operative (D) CT scan image of the patient.

RESULTS

The current study included 25 patients distributed as 22 (88%) males and 3 (12%) females. The age ranged from 4 to 47 years. The commonest mode of trauma was motor vehicle accidents sustained by 14 (56%) patients while 7 (28%) patients were hit by hard objects and 4 (16%) patients fell from a height. Ten (40%) patients were fully conscious on admission and the rest of the patients had a depressed level of consciousness with a Glasgow coma scale (GCS) score ranging from 10 to 14. Sixteen (64%) patients were intact as regards motor power while 9 (36%) had weakness of different degrees and distributions and 2 (8%) had speech difficulties. The pre-operative temperature ranged from 36.8°C to 38.5°C with an average of 37.3°C.

The highest pre-operative 1^st hour erythrocyte sedimentation rate (ESR) was 40 mm and the average ESR was 16.25 mm. on the other hand the pre-operative total leucocytic count ranged from 4200 to 13000 cell per mm³ with an average of 8200 cell per mm³.

One patient had a midline parieto-occipital fracture and two patients had a frontal midline fracture while 13 (52%) patients had right and 9 (36%) patients left sided fractures. Out of the patients included 13 (52%) patients suffered an underlying associating pathology in the pre-operative CT scan mostly a hemorrhagic brain contusion. Figure (5) shows the anatomical distribution of fractures.

Dural laceration was found in 11 (44 %) patients and intra-operative cerebrospinal fluid leakage was encountered in 7 (28 %) none of whom had a post-operative leak. In addition, 4 (16 %) patients had brain laceration with or without external herniation. The degrees of contamination and tissue destruction are showed in figure (6).

The average surgical timing was 130 minutes and the shortest time lag from trauma to surgery was 3 hours while the longest was 36 hours with an average delay of about 11 hours. Different modalities of plastic repair and their distribution are outlined in figure (7).

In the 1^st post-operative 24 hours 11 (44 %) patients had core temperature readings above 38° C. However, all of them were easily controlled by simple antipyretics. Two patients showed early post-operative signs of superficial wound infection that were adequately controlled by local wound care and systemic antimicrobial therapy. The average post-operative hospital stay was 5.1 days ranging from 2 days to 12 days with the longer post-operative stay periods in patients having associated pathologies in admission CT scan. All patients were discharged with a GCS score of 15. On the other hand 19 (80 %) patients were discharged with no neurological impairment while the rest of the patients suffered variable degrees of focal neurological deficits. The follow up periods ranged from 2 to 18 months with an average of 6.3 months.

Figure 5. Location of fractures.

Figure 6. Degrees of contamination and tissue destruction.

Figure 7. Modalities of plastic repair.

DISCUSSION

Compound calvarial fractures are not an uncommon pathology when dealing with the head injured patients. Classical opinions regarding treatment of compound cases were based on war-time experience of missile injuries, and total removal of all indriven and fractured bone fragments was advocated.³

In the current study, no cases of infection necessitating re-operation or prolonged antimicrobial therapy were encountered and even in the two cases with an evidence of superficial wound infection the situation was easily controlled. Soft tissue and bone healing occurred with acceptable cosmetic results that not a single patient sought for further plastic revisions.

Avoidance of such a second operation to correct the deformity not only lessens the overall costs of treatment but also helps patients to avoid the medical risks added by another surgery. Additionally, the psychological trauma from either living a period of time with a disfiguring deformity or even from waiting for another surgery scheduled several months later can be avoided without adding significant risks to the patient.

Selection of the implant material used for reconstruction is still controversial.⁴ Choice of the repair material in the current study was affected by the availability of such materials at the center in which the patient is treated and the time at which the surgery was done.

In 1972, Braakman³ found that replacement of all or part of the bone fragments is justified in clean or contaminated compound injuries, provided that the dura can be closed or covered and that meticulous debridement of scalp, periosteum, dura and sometimes neural tissue, is vital.

Akram et al.⁵ stated that Bone fragment removal in compound depressed skull fractures, regardless of the degree of wound contamination, is not obligatory and primary bone fragment replacement is a suitable alternative, which also avoids a second cranioplasty.

On their study on replacement of bone fragments during repair of compound-depressed skull fractures in children Blankenship et al.⁶ adopted protocol for bone fragment treatment intra-operatively and they used intravenous antibiotics peri-operatively. They included 31 cases in their study and concluded that at follow-up (average of 26.5 months), all patients had solid bone fusions and healed wounds. They had no wound infections or osteomyelitis. No patient required subsequent cranioplasty. Consequently, they stated that bone fragment removal during surgical treatment of compound-depressed skull fractures, regardless of the degree of contamination, the presence of dural laceration, or the degree of neural tissue injury, is not a must and that bone fragment replacement avoids a second operation for cranioplasty.⁶

Additionally, Bollock et al.¹ confirmed that primary bone fragment replacement is a valid surgical option in the absence of gross wound infection at the time of presentation, immediate replacement of bone fragments seems not to increase the incidence of infection if surgery is performed expeditiously, and this replacement eliminates the need for subsequent cranioplasty and its attendant risks and complications.¹ This was supported by the opinion of Adeloye and Shokunbi who also recommended primary repair of skull defects with bone fragments as the treatment of choice during debridement of compound depressed calvarial fractures present in hospital within 24 hours of injury.⁷

Conclusion

Early single stage elevation, debridement and cranioplastic repair of compound calvarial fractures is a valid treatment scenario that can be adopted whenever possible with no added risk of infection.

[Disclosure: Authors report no conflict of interest]

REFERENCES

1.        Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of depressed cranial fractures. Neurosurgery. 2006 Mar; 58 supp 3: s52-7.

2.        Wylen EL, Willis BK, Nanda A: Infection rate with replacement of bone fragment in compound depressed skull fractures. Surg Neurol.  1999 Apr; 51(4): 452-7.

3.        Braakman R. Depressed skull fracture: data, treatment, and follow-up in 225 consecutive cases. J Neurol Neurosurg Psychiatry.  1972; 35: 395-402.

4.        Nayak PK, Mahapatra AK. Primary reconstruction of depressed skull fracture -The changing scenario. Ind J Neurotrauma.  2007; 5(1): 35-38.

5.        Akram M, Ahmed I, Qureshi NA, Bhatti SH, Ishfaq A. Outcome of primary bone fragment replacement in compound depressed skull fractures. J Coll Physicians Surg Pak. 2007 Dec; 17 (12): 744-8.

6.        Blankenship JB, Chadduck WM, Boop FA. Repair of compound-depressed skull fractures in children with replacement of bone fragments. Pediatr Neurosurg.1990-1991; 16 (6): 297-300.

7.        Adeloye A, Shokunbi MT. Immediate bone replacement in compound depressed skull fractures. Cent Afr J Med. 1993 Apr; 39(4): 70-3.