Frontal Fracture Clinical Presentation

  • Author: Thomas Widell, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 17, 2011
 

History

  • Since maxillofacial fractures are the result of trauma, primary survey and attention to ABCs take priority.[1, 3, 5, 6, 9, 10, 11] Focus initially on patency of airway, control of cervical spine, and whether the patient is having difficulty breathing, and determine if the patient is experiencing symptoms of shock or neurologic impairment.
  • Once life threats have been addressed, obtain a thorough history.
    • Allergies
    • Medications
    • Medical history
    • Last meal
    • Events leading to injury
  • Question patient about injury.
    • Does patient have epistaxis or clear fluid draining from nares or ears?
    • Did patient lose consciousness?
    • Has patient had any visual problems, such as double or blurred vision?[12]
    • Has patient had any hearing problems, such as decreased hearing or tinnitus?
    • Do the teeth come together normally and is patient able to bite down without pain?
    • Does patient have areas of numbness or tingling on the face?
    • In women, ask if the injury was from a partner or if they feel threatened by anyone.
    • In children, ask questions to determine if child abuse is an issue.
Next

Physical

  • Complete exam of the face is necessary since multiple injuries can occur easily. Portions of the exam specific for the frontal bone are marked with an asterisk (*).[13]
    • Inspect face for asymmetry, which is often easiest to do looking down from the head of the bed.
    • *Inspect open wounds for foreign bodies and palpate for bony injury.
    • *Palpate bony structures of the supraorbital ridge and frontal bone for step-off fractures.
    • *Examine eyes thoroughly for injury, abnormality of ocular movements, and visual acuity.[12]
    • Inspect nares for telecanthus and widening of the nasal bridge. Palpate for tenderness and crepitus.
    • Inspect nasal septum for septal hematoma and clear rhinorrhea, which suggests cerebrospinal fluid (CSF) leak.
    • Palpate zygoma along its arch as well as its articulations with frontal bone, temporal bone, and maxillae.
    • Check facial stability by grasping teeth and hard palate, then gently pushing back and forth, then up and down, feeling for movement or instability of midface.
    • Inspect teeth for fracture and bleeding at gum line, a sign of fracture through alveolar bone. Test for stability.
    • Check teeth for malocclusion and step-off.
    • Palpate mandible for tenderness, edema, and step-off along its symphysis, body, angle, and condyle anterior to ear canal.
    • *Evaluate supraorbital, infraorbital, inferior alveolar, and mental nerve distributions for hypoesthesia and anesthesia.
    • Frontal fracture is suspected in patients who experience high-impact, blunt trauma and have a physical exam demonstrating step-off of the frontal bone or supraorbital ridge. Epistaxis or CSF leak merits further evaluation if the patient has a forehead injury.
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Contributor Information and Disclosures
Author

Thomas Widell, MD  Vice Chairman, Assistant Professor, Department of Emergency Medicine, Rosalind Franklin School of Medicine/The Chicago Medical School, North Chicago, Illinois; Associate Residency Director, University of Chicago Emergency Medicine Program, Chicago, Illinois; Program Director Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center, Chicago, Illinois

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD, FACEP  Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Hendler BH, Rosen P. Maxillofacial trauma. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998:1093-1103.

  2. McGill J, Ling L, Taylor P. Facial trauma. Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992:51-76.

  3. Smith RG. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins Publishers; 1991:337-43.

  4. Sullivan W. Trauma to the face. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996:242-69.

  5. Thomas SH, Shepherd SM. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott, Williams & Wilkins; 1996:408-18.

  6. Hasan N, Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill Co Inc; 2004:chap 257, p1583-1590.

  7. McKay MP. Facial trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine, Concepts and Clinical Practice. Vol 1. 6th ed. Philadelphia, PA: Mosby Elsevier; 2006:382-98/chap 39.

  8. Muminagic S, Masic T, Babajic E, Asotic M. Managment of frontal sinus fracture: obliteration sinus with cancellous bone graft. Med Arh. 2011;65(4):250-1. [Medline].

  9. Kummoona RK. Missile War Injuries of the Face. J Craniofac Surg. Nov 5 2011;[Medline].

  10. Kolodziej MA, Koblitz S, Nimsky C, Hellwig D. Mechanisms and consequences of head injuries in soccer: a study of 451 patients. Neurosurg Focus. Nov 2011;31(5):E1. [Medline].

  11. Guo L, Guo W, Li R, Sheng L, Yang B, Tang W, et al. Analysis of maxillofacial injuries caused by the 2010 Yushu earthquake in China. Emerg Med J. Oct 13 2011;[Medline].

  12. Spoor T, Ramocki JM, Kwito GM. Ocular trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996:225-41.

  13. Snell RS, Smith MS. The face, scalp, and mouth. In: Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993:206-241.

  14. Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. Jul 2003;61(7):785-92. [Medline].

 
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