In a depressed skull fracture with a subdural hematoma, which surgical intervention is indicated to elevate the depressed bone and remove free fragments?

• A. Life-support measures until stabilization
• B. Immediate burr holes for rapid decompression
• C. Conservative management with close observation
• D. Craniotomy for evacuation of blood and decompression

Answer: (D)

The key idea is that a depressed skull fracture with an associated subdural hematoma requires direct, open access to the skull to lift the depressed bone, remove free fragments, and evacuate the hematoma. A craniotomy provides this access, allowing the surgeon to elevate the bone flap to its normal contour, remove clot and any free fragments, inspect and repair the dura, and then decompress the brain safely. This direct decompression and debridement address the mass effect and potential ongoing bleeding more effectively than less invasive options. Burr holes can relieve pressure but cannot adequately elevate the depressed bone or remove intracranial fragments, and conservative management or merely stabilizing the patient does not treat the mass effect or the intracranial injury. Therefore, craniotomy for evacuation of blood and decompression is indicated.