Depressed Skull Fractures
Depressed skull fractures are traumatic fractures in which fragments of the skull bone are pushed inward toward the brain surface. They may be closed (simple) or open (compound); open fractures carry a high risk of infection. Treatment is planned according to the type of fracture, the degree of depression and any accompanying injuries.
Last updated: 2026-06-07
Definition
A depressed fracture is defined as inward displacement of skull bone fragments toward the brain surface by more than the thickness of the inner table of the bone. It accounts for a significant proportion of all skull fractures. If the overlying skin and the brain's membrane (dura) are intact it is called a simple (closed) fracture; if the skin and dura are torn and the bone is exposed to the outside it is called an open (compound) fracture. In infants the flexible skull can bend inward and depress in a 'ping-pong ball' pattern.
Causes and Mechanism
The most common causes are road traffic accidents, falls, blunt-object impacts and work accidents. A high-energy blunt impact to a limited surface fractures the bone and pushes the fragments toward the brain. The depressed fragments can cause a dural tear, venous sinus injury, cortical bleeding or contusion and sometimes an epidural or subdural hematoma. In open fractures, the connection with the outside environment markedly increases the risk of infection (meningitis, brain abscess, bone infection).
Symptoms
Local findings include swelling at the site of trauma, a skin laceration, a palpable bony depression and, in open fractures, leakage of cerebrospinal fluid (clear discharge from the nose or ear). Neurological findings vary with any accompanying intracranial lesions; there may be a change in consciousness, weakness on one side of the body, speech or vision problems and seizures. In open fractures, attention is paid in the later period to signs of infection such as fever, neck stiffness and confusion.
Diagnosis
Non-contrast brain CT is the gold standard; the bone window shows the fracture line, the degree of depression and the position of the bone fragments. The brain window is used to assess any accompanying hematoma, contusion and air within the skull (pneumocephalus). Three-dimensional CT reconstruction aids surgical planning. For fractures near a sinus, CT or MR venography may be considered to assess the vessels. Where cerebrospinal fluid leakage is suspected, a beta-2 transferrin test on the discharge confirms the diagnosis.
Treatment Options
Treatment is individualized according to the type of fracture, the degree of depression, the integrity of the dura and any accompanying lesions. For simple, closed fractures with minor depression and no neurological signs, conservative management with observation, pain control and seizure prophylaxis where needed may be appropriate. Surgery is performed for significant depression, an open fracture, a dural tear, a hematoma causing mass effect, or a fracture in a cosmetically important region; the depressed fragments are elevated and returned to their anatomical position, the dura is repaired and, where needed, the bony structure is reconstructed by cranioplasty. In open fractures, wound cleaning (debridement) and antibiotic treatment are important in preventing infection.
Course and Recovery
Recovery is generally good in isolated, simple closed fractures. In open fractures, infection control determines the course; where there is an accompanying hematoma or contusion, the severity of the underlying brain injury does so. Because of the risk of early and late seizures, patients are monitored for a period, and antiepileptic treatment is continued where needed. Bone healing and possible complications are assessed with follow-up imaging. Outcomes vary from patient to patient and no result can be guaranteed.
References
- Greenberg MS. Greenberg's Handbook of Neurosurgery. 10th ed. Thieme; 2023:1062-1064.
- Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of depressed cranial fractures. Neurosurgery. 2006;58(3 Suppl):S56-S60.
- Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury. 4th ed. Neurosurgery. 2017;80(1):6-15.
This article is for general information and does not replace a medical examination. Diagnosis and treatment decisions are individual.