Treat the Patient

David's x-ray with depression top left

David is a 19 year old who was referred from a hospital 100 miles away with a diagnosis of "depressed skull fracture".  He was cutting down a tree 2 days earlier when it fell and hit him on the head and shoulder.  He was seen the next day complaining of both headache and shoulder pain.  X-rays were obtained and a depressed skull fracture was present and he was sent to our hospital because we do orthopedics. 
 
David appeared quite well and I could only find some minor scratches on his head with no swelling.  His mother could not remember him hitting his head when he was younger.  I elected to obtain a lateral skull x-ray since I could not find a depression on his skull to go with his x-ray finding.  The additional x-ray also showed the depressed skull fracture.  By then David's father arrived and remembered David had fallen out of a Mango tree as a young child.  

David with Parents

Conclusion:  Indeed David had sustained a depressed skull fracture, but as a child and not 2 days earlier from the falling tree.  

David's case is a good reminder to treat the patient and not necessarily the lab or x-ray finding.