The missing bone flap — mobilizing a trephined skull
| Patient | 56M, acute phase |
|---|---|
| Injuryacute subdural haematoma evacuated; decompressive craniectomy for refractory intracranial pressure | |
| Severity | Worst GCS 7 |
| Days since injury | 6 |
| Before the injuryIndependent. Bus driver, ex-smoker, no previous neurology. | |
| Also on the chartHypertension, on treatment | |
| PrecautionsSkull defect — helmet for all upright activity; no head-dependent positioning; No Valsalva or straining through transfers — coach the breath; Left-sided weakness emerging — fall risk on standing | |
Test yourself
How is he mobilized with the skull open?
The teaching
Decompressive craniectomy buys survival by removing the wall, and rehabilitation then runs with the wall missing: helmet for every upright minute, no dependent head-down positioning, no straining, and a stop rule tied to neurological change. Reconstruction is not the end of the story but a chapter of it — early cranioplasty is associated with greater improvement. What you do with it: mobilize protected and graded, treat the flap as a window you read every session, and push the timeline toward the bone going back.
- A bulging flap, a newly sunken flap with symptoms, or deepening drowsiness — escalate the same hour
- Any unprotected upright time — the helmet is part of the prescription, not an accessory
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Hutchinson PJ et al. Trial of decompressive craniectomy for traumatic intracranial hypertension (RESCUEicp). N Engl J Med. 2016. Carney N et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017 · Malcolm JG et al. Early cranioplasty is associated with greater neurological improvement: a systematic review and meta-analysis. Neurosurgery. 2018. Hutchinson PJ et al. Trial of decompressive craniectomy for traumatic intracranial hypertension (RESCUEicp). N Engl J Med. 2016 · Carney N et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017. Malcolm JG et al. Early cranioplasty is associated with greater neurological improvement: a systematic review and meta-analysis. Neurosurgery. 2018