Frontal Fracture

Updated: Apr 02, 2016
  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
  • Print
Overview

Background

Maxillofacial fractures result from blunt or penetrating injury. Blunt injuries are far more common, resulting from vehicular accidents, altercations, sporting-related trauma, occupational injuries, and falls. Penetrating injuries mainly are the result of gunshot wounds, stabbings, and explosions. [1, 2, 3, 4, 5, 6, 7, 8]

Hippocrates described an array of facial injuries as long ago as 400 BCE.  During the early 20th century, Sir Harold Gilles, father of plastic surgery, taught army personnel about breathing problems in patients with facial injuries and to place them supine to maintain an airway. René Le Fort described 3 basic types of fractures. Endotracheal anesthesia and radiography developed during the First World War led to a better understanding and treatment of facial fractures. During the Second World War, a multidisciplinary approach to treatment of facial fractures continued to improve the outcomes of severely injured soldiers. Advent of CT reconstruction of facial bones, along with new surgical techniques, has dramatically improved the final appearance patients who have sustained bony injuries.

See the image below.

Anterior and lateral views of the frontal sinus. T Anterior and lateral views of the frontal sinus. These figures demonstrate the relative thickness of the anterior and posterior tables, as well as the relationship of the frontal sinus to the orbits, ethmoid sinuses, and anterior cranial fossa.
Next:

Pathophysiology

The ype of object striking the face and force behind the object are the main determinants of whether a person sustains soft-tissue or bony injury. In automobile accidents, striking a hard dashboard is more likely to cause bony injury than striking a padded dashboard or an airbag. Striking the steering wheel concentrates the force more than striking the flat surface of the dashboard. [7] This also holds true for altercations with a bat, as compared to a bare fist or boxing glove. Penetrating injury from a shot gun at a distance is not likely to cause fractures. Bullets from low-velocity guns are likely to cause fractures; high-velocity bullets cause fractures and extensive soft-tissue damage.

The amount of force needed to fracture different bones of the face has been studied; injuries have been divided into those that require high impact to fracture (greater than 50 times the force of gravity [g]) and those that require a low impact to fracture (50 g or less).

  • High impact
    • Supraorbital rim - 200 g
    • Symphysis of the mandible - 100 g
    • Frontal-glabellar bone - 100 g
    • Angle of mandible - 70 g
  • Low impact
    • Zygoma - 50 g
    • Nasal bone - 30 g

Frontal bone and supraorbital fractures require high-energy impact. Forces this strong may indicate intracranial injury. Frontal bone contains the frontal sinus, and fractures of only the anterior (outer) table or both anterior and posterior (inner) tables are possible. [9] Associated fractures of the supraorbital ridge, nasoethmoidal complex, and other facial bones also may occur (see Fractures, Face). [10, 1]

For more information, see Medscape's Trauma Resource Center.

Previous
Next:

Epidemiology

Approximately 3 million facial injuries occur annually; however, most do not involve maxillofacial fractures. [10, 11, 12, 13, 14, 1, 2] One study placed the incidence of severe maxillofacial injury (fractures and lacerations) at 0.04-0.09% for persons in motor vehicle accidents. Incidence of fractures due to motor vehicle injuries is higher in rural areas, and altercation-related fractures are more frequent in urban areas.

Incidence of other major injuries is as high as 50% in high-impact fractures, while it is 21% for low-impact fractures. Motor vehicle accidents are more likely than violent altercations to cause other injuries. Mortality rate in high-impact fractures is as high as 12%, yet deaths rarely occur from maxillofacial injury. The incidence of cervical spine injuries associated with frontal fractures has been reported in the 0.2-6.0% range.

In one study, upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, and panfacial, respectively. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% for middle and 4.0% for lower face fractures. [15]

Adult male-to-female ratio is 3:1. Consider domestic violence in women with facial injuries not related to a motor vehicle crash.

Male predominance is reduced to 2:1 in children. Consider child abuse when facial injuries are found in children.

In a retrospective review of facial fractures at a level 1 trauma center from 2000 to 2012 in 285 patients aged 18 yr or younger, the mean age was 14.2 yr with a male predominance (77.9%). The mechanisms of injury were assault in 108 (37.9%), motor vehicle accident in 68 (23.9%), pedestrian struck in 41 (14.4%), fall in 26 (9.1%), sporting accident in 20 (7.0%), and gunshot injury in 16 (5.6%). The mean Glasgow Coma Scale (GCS) on arrival to the ED was 13.7. The most common fractures were those of the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma (7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage was present in 70 patients (24.6%). Fractures of the zygoma, orbit, nasal bone, and frontal sinus/bone were significantly associated with intracranial hemorrhage (P<0.05), and fractures of the zygoma and orbit were significantly associated with cervical spine injury (P<0.05). [4]

Previous