Comparison of the neurological outcomes and infection rate in surgical and conservative management of compound depressed skull fractures

Background: Depressed skull fractures (DSFs) constitute a significant chunk of head injuries. As per level 3 evidence of recent brain trauma foundation guidelines, depressed fracture segments greater than the thickness of the calvaria should undergo operative intervention to prevent infection and to improve neurological outcomes. This study was done to refute the Brain Trauma Foundation guidelines of level 3 evidence by non-surgical management of those depressed skull fractures in which surgical management is indicated, and we aimed to assess and compare the incidences of infection rate and neurological outcomes in patients of surgical and conservative management of depressed skull fractures. Material and methods: This prospective interventional study included 102 patients with compound depressed fractures with a surgical indication as per “Brain Trauma Foundation Guidelines 2006 Level 3 Management” from August 2020 to December 2021. A minimum of 6 months of follow-up was done. Those who gave consent for surgery were included in the surgical group, and those who refused were included in the conservative group, and both groups were compared. In the surgical group, the method of choice recommended was the conventional method of elevation of the depressed fracture segment and debridement, and in the conservative group, simple debridement and suturing after saline and antibiotic wash followed by IV antibiotics were given. Statistical Analyses: Data were analyzed using the SPSS software (version 23.0) for Windows. Qualitative variables were analyzed using chi sq. test and quantitative data by Student's t-test. Results: Out of 102 patients, 42 were managed surgically and 60 were managed conservatively. The majority, 44.1%, of depressed skull fractures were present over the frontal bone. The overall complication rate was 20.58% (21/102). 68.29% of patients contributed to neurological complications, and the rest (31.70% of complications) were infective. No significant difference was found in comparing the neurological outcomes and infection rate in non-surgically versus surgically managed groups. Conclusion: Conservatively managed depressed fractures have equivalent neurological outcomes and infective complications when compared with surgical management. The results of our research will provide benefits towards more conservative management with adequate wound debridement and antibiotics so that these patients can also be managed in peripheral rural hospitals and avoid unnecessary referrals to higher tertiary centers.