Isolated Depressed Fracture of the Inner Table of the Skull with an Intact Outer Table: A Rare Case Report

Isolated depressed fractures of the inner table of the skull with an intact outer table are exceedingly rare injuries that are frequently underdiagnosed because the overlying intact outer table preserves the external cranial contour, producing no palpable skull deformity. A 19-year-old male presented to the neurosurgery outpatient department with persistent headache 3 days following a road traffic accident. He was neurologically intact (Glasgow Coma Scale 15), and local examination revealed a sutured scalp wound without palpable depression, step deformity, or crepitus. Non-contrast computed tomography (NCCT) of the head, evaluated on dedicated bone-window and parenchymal views, demonstrated a depressed fracture involving the inner table of the right parietal bone with preservation of the outer table, widening of the diploic space, an intraosseous hematoma, and a 9-mm epidural hematoma. Additional findings included right parietal hemorrhagic contusions and traumatic subarachnoid hemorrhage. Given the patient's neurological stability and absence of significant mass effect, conservative management with close neurological monitoring and symptomatic treatment was instituted. The patient remained clinically stable and was discharged without complications. This case highlights the importance of maintaining a high index of suspicion and the critical role of careful evaluation of NCCT head on dedicated bone-window and parenchymal views in detecting occult inner-table fractures and associated intracranial injuries in patients with persistent symptoms after head trauma.