BackgroundDepressed skull fractures (DSFs) are features of traumatic brain injury (TBI), frequently associated with intracranial damage and long-term functional impairments. The neurological outcomes of the perioperative management are yet to be evaluated. This study aimed to assess the effect of surgical timing and perioperative clinical radiological factors on functional outcomes in DSFs.MethodsThis prospective cohort study enrolled 205 patients with DSFs at a tertiary neurosurgical center in Uganda. Patients underwent surgical management, with the primary exposure variable being surgical timing (<= 48 h vs. >48 h). Functional outcomes at six months were assessed using the Glasgow Outcome Scale-Extended (GOSE), categorized into favorable (GOSE 5-8) and unfavorable (GOSE 1-4). Multivariate regression models were used to identify functional outcome predictors.ResultsThe median-age was 24 years (IQR = 15-31), 89.5% were male, and 49.73% were assault victims. Approximately 73.1% had an admission GCS > 13. The frontal bone was most commonly involved (46.2%). Early surgical intervention (<= 48 h) significantly reduced the risk of surgical site infections (SSIs) (p = 0.01) and shortened hospital stays. However, surgical timing had no significant association with functional outcomes adjusted risk ratio (ARR): 0.95; 95%CI: 0.35-2.61; p = 0.92. Several perioperative factors were strongly linked to unfavorable outcomes, including ASA class 3 (ARR: 5.09, 95%CI: 2.11-12.2; p < 0.01), compound DSFs (ARR: 3.18; 95%CI: 1.70-5.96; p < 0.01), and midline shift >= 5 mm (ARR: 2.84; 95%CI: 1.50-5.39; p < 0.01).ConclusionsEarly surgery of DSFs reduces the infection rates and hospital length of stay; however, it does not significantly impact the 6-months functional outcomes. The outcomes are instead influenced significantly by clinical radiological perioperative factors such as the ASA classification, compound type, midline shift >= 5 mm, and others. We advocate for an aggressive treatment for increased ICP to improve the outcomes, and an early surgical intervention for infection reduction.