Compound elevated skull fractures: a retrospective descriptive study.

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 tertiary referral neurosurgical department.
Methods: Medical records of consecutive patients admitted from January 2005 to December 2018 with compound elevated skull fractures at the single neurosurgical referral hospital were retrospectively evaluated. Data was analyzed for demographics, clinical presentation, mechanisms of injury, neuro-radiology findings, management and outcomes.
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: Type 1 - fractured segment with minimal loss of contact with rest of cranial vault, Type 2 - fractured segment with partial loss of contact with rest of cranial vault, Type 3 - fractured segment with complete loss of contact with rest of cranial vault. 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. Prompt neurosurgical management with appropriate operative management of dura and elevated bone fragment reduces morbidity from septic complications.