Management of Depressed Skull Fracture with GCS 15

Immediate Diagnostic Evaluation

A patient with a depressed skull fracture and GCS 15 requires immediate CT imaging to assess for underlying brain injury, dural violation, and depth of depression, followed by neurosurgical consultation for operative planning, as depressed skull fractures are high-risk features that mandate imaging regardless of neurological status 1, 2, 3
CT imaging is mandatory for any patient presenting with a depressed skull fracture, even with a GCS of 15, as this represents a high-risk criterion in validated clinical decision rules 1, 2, 4
The Canadian CT Head Rule identifies "suspected open skull fracture" as one of five high-risk predictors requiring CT imaging, with 100% sensitivity for predicting need for neurosurgery 4, 5
The New Orleans Criteria similarly mandate CT for any physical evidence of trauma above the clavicle, which includes depressed skull fractures 4
In prospective studies, depressed skull fracture was specifically identified as a criterion where no patient without this finding required neurosurgical intervention, but patients with this finding had significantly elevated risk 1, 2, 3

All patients with depressed skull fractures require hospital admission regardless of GCS score, as this represents a structural injury with potential for delayed complications 1, 2, 3
Even patients with GCS 15 and depressed skull fractures had an 8% rate of positive CT findings requiring intervention in prospective studies 1, 2
The evidence supporting safe discharge after negative CT applies only to patients with mild TBI without skull fractures 6
Do not discharge a patient with a depressed skull fracture based solely on GCS 15, as the structural injury itself is a high-risk feature requiring imaging and potential intervention 1, 2, 4
Do not delay CT imaging to observe the patient, as depressed skull fractures require immediate radiographic assessment 4