Clinicopathological Features of Post-Traumatic Scalp Swellings in Adults with Depressed Skull Fractures

Objectives: While traumatic brain injury (TBI) is highly prevalent, post-traumatic scalp swellings remain poorly characterized in the literature. This study investigated the histopathological features of scalp swellings in adults with depressed skull fractures and examined their correlation with clinical and radiological findings. Methods: We conducted a prospective observational study of 20 adult patients presenting with open depressed skull fractures requiring surgical debridement. Excised scalp tissue samples were subjected to histological analysis and findings were correlated with clinical characteristics and radiological imaging. Results: Fat necrosis within the subcutis was observed in all patients, representing a consistent and previously underrecognized feature of post-traumatic scalp swellings. Acute inflammatory infiltrates were identified in 69% of soft swellings compared with 25% of firm swellings. Conversely, chronic inflammation was present in 100% of firm swellings but only 13% of soft swellings. Radiological assessment uniformly demonstrated subgaleal hematomas, with limited concordance between imaging and histological features due to sampling and preparation artifacts. Conclusion: Fat necrosis of the subcutis was a novel universal finding in post-traumatic scalp swellings; clinically, bogginess mapped to acute inflammation and firmness to chronic change. These results refine bedside interpretation, highlight CT’s limits for scalp pathology, and show that swelling characteristics alone do not predict significant intracranial injury, informing potential benefits of operative handling of the subcutis and offering forensic value.