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Head trauma in the pediatric population carries a high rate of morbidity and mortality. The major causes of head trauma are related to falls, recreational activities, motor vehicle accidents, and gunshot wounds. Traumatic brain injury (TBI) can occur after severe head trauma and is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force. Intracranial edema and herniation are common consequences of a TBI in pediatric patients and are commonly relieved via decompressive craniectomy. This case study describes a 13-year-old male presenting to the trauma center after an unhelmeted all-terrain vehicle (ATV) accident with a positive head strike and loss of consciousness. The evaluation revealed extensive skull fractures extending from the frontal to the occipital lobe with brain exposure. Computed tomography (CT) scan of the head demonstrated extensive, open skull fractures with significant displacement of the exposed brain, extensive bilateral parietal and frontal bone fractures, and bilateral temporal bone displaced fractures more extensive on the left. A bilateral hemicraniectomy was performed due to diffuse cerebral edema and a left frontal ventriculostomy was placed to monitor and manage intracranial pressure (ICP). It is believed that the unique presentation of an open skull fracture with an exposed brain acted as a decompressive method allowing for extreme lifesaving measures to be performed to save the patient. Further exploration is needed to truly understand the effects of the unique injury presentation and the role of an open fracture in the delay of increased ICP.