Retrospective chart review of surgical management of compound elevated skull fractures.

Abstract

Background: Traumatic skull fractures have been traditionally classified into those that involve the base or vault with distinct entities linear or depressed. Compound elevated skull fracture is a newer entity with scanty reports in the literature. Objective: To describe the clinical presentation, neuro-radiology findings by development of a classification system, medical and surgical management, and complications of patients with compound elevated skull fractures at a busy Neurosurgical Department in Durban, South Africa. Methods: Medical records of consecutive patients admitted from January 2005 to December 2018 with compound elevated skull fractures at Inkosi Albert Luthuli Central Hospital were retrospectively evaluated. Data was analysed for demographics, clinical presentation, mechanisms of injury, neuro-radiology findings, management and outcomes. Neuro-radiological images were used to develop a classification system. Results: Eighteen patients were included in this series with a median age of 28 years, median admission Glasgow Coma Scale was 12. Ten patients presented with focal neurological deficits which included hemiparesis [n=8, 44%] and unilateral afferent pupil deficit [n=2, 11%]. Intra-cerebral haematoma was the most common associated neuro-radiological finding [n=10, 55%] followed by acute extradural haematoma [n=4, 22%]. Three distinct neuro-radiological subtypes were identified. All patients underwent surgical debridement and of which 11 [61%] required duroplasty and 10[55%] re-placement of elevated bone flap. Septic complications included meningitis [n=5, 27%], brain abscess [2, 11%] and surgical site infection [n=1, 5%]. Seventeen patients had favourable outcomes at discharge (Glasgow Outcome Scale 4 or 5). Conclusion: Compound elevated skull fracture is an additional subtype of skull vault fracture. Use of the originally developed classification system is important and infrequently described type of skull fracture. We recommend early surgical intervention which includes careful management of dura and elevated bone fragment reduces morbidity from septic complications.