The patient came to the emergency of Shmaisani hospital 01-April-2009 transferred from Aqaba with clinical history of massive blunt injury to the head during work with subsequent LOC for more than 2 hours 3 days ago.

CT-scan of the brain and skull X-ray showed depressed fracture of the right parietal bone.

On examination the patient is still drowsy with crushed cut wound in the right parietal region with dirty ugly wound.

The patient was moving all limbs without neurologic deficit and he complained of neck and chest pain.

Considering that the wound is dirty and the bone fragments were depressed it was decided to explore the wound and explore the dura. The fragmented bones were removed in that fashion so as to use them later. There was hair and dirt even reaching the intact dura. After cleaning of the dura of all compressed bony elements and washing it out of dirt, some of acceptable bony fragments were used to fill the bony defect aided with nylon stitches. Debridement of the wound and routine closure.

Smooth postoperative recovery.

In infants with pig-pong depressed fracture can be managed with tiny wound with subsequent elevation of the bone.

In adults with compound dirty wound removal of all bones is a must  with inspection of the dura. Meticulous cleaning of all the elements and removal of the severely crushed tissues decrease the possible postoperative osteomyelitis and possible hidden complications. The internal layers of the bone were separated from the outer part and they were causing the major depression.

So as to avoid using substitutes for the bone, the bone fragments must be removed with care, cleaned studied and if they are acceptable, to use them to fill the bony defect.