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Background: Compound depressed fractures have conventionally been managed surgically with elevation and debridement to avoid infection, especially when there is dural penetration, nonetheless with little evidence. This study was to prospectively compare outcomes after simple suturing and elevation debridement in patients with compound depressed fractures. Methods: Patients of compound depressed fracture with GCS of five or more, no serious systemic injury, and no significant mass effect were prospectively studied for various factors in relation to infection, hospital stay, survival, and late post-traumatic seizures. Univariate and multivariate analyses were performed using SPSS21. Results: Of the total 232 patients with complete clinico-radiological and follow-up data, 183 underwent simple cleansing and suturing, and 49 underwent surgical elevation debridement. The surgical group at baseline had significantly lower GCS, greater dural violation, and brain matter herniation compared to the conservative arm. Univariate analysis showed simple suturing group to have significantly shorter hospital stay (2.4 vs. 10.3 days) ( p < 0.001), lesser infection among survivors (4 vs. 21 %) ( p = 0.001), and greater 'survival with no infection' (85 vs. 69 %) ( p = 0.01). Multivariate analysis adjusting for age, sex, GCS, dural penetration, and surgical intervention confirmed significantly shorter hospital stay ( p < 0.001) and lesser infection among survivors ( p = 0.02) in the simple suturing group. Overall, there was no benefit offered by surgical debridement. Simple suturing had a better outcome in most subgroups, except in those with brain matter herniation and GCS 5-8, which showed non-significant benefit with surgical intervention. Conclusions: Simple suturing seems to be an equally good option in patients with compound depressed fracture with no significant mass effect or brain matter herniation. [ABSTRACT FROM AUTHOR]