Inner table skull fracture with intact outer cortex: a rare case report and literature review.

Introduction and Importance: Isolated inner table skull fractures are exceptionally rare, particularly following penetrating head injuries caused by explosion fragments. These injuries pose significant diagnostic and management challenges due to their atypical presentation and potential intracranial complications. Case Presentation: We report the case of a 50-year-old woman who sustained a fragment injury to the head during a military assault in a war zone, when a grenade exploded nearby. Computed tomography (CT) revealed a depressed inner table skull fracture with an intact outer cortex, accompanied by subdural hematoma. Despite the high-risk mechanism, the patient maintained full consciousness with a Glasgow Coma Scale score of 15/15. Conservative management was initiated, including wound care, antibiotics, corticosteroids, and close clinical and radiologic monitoring. The patient demonstrated progressive improvement and was discharged in stable condition. Although operative management was initially considered at the referring facility, neurosurgical reassessment supported conservative management with close observation. Clinical discussion: Depressed fractures confined to the inner table are extremely uncommon and may be overlooked on initial assessment. The intact outer cortex can mask the severity of the underlying injury, increasing the risk of delayed complications if not promptly identified. CT imaging is crucial for accurate diagnosis, and management decisions should be tailored based on neurological status and associated intracranial findings. Conclusion: This case highlights a rare presentation of an isolated inner table skull fracture resulting from a penetrating explosive injury. Early recognition and conservative management can result in favorable outcomes when neurological function is preserved.