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Fracture, Frontal

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
Contributor Information and Disclosures

Updated: Mar 6, 2008

Introduction

Background

Hippocrates described an array of facial injuries as long ago as 400 BC. In 1823, von Graeffe described an elastic tube placed in the nose to maintain an open airway. 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, a Frenchman, studied cadavers in 1901. He 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.

Pathophysiology

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.

Type 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. 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. Associated fractures of the supraorbital ridge, nasoethmoidal complex, and other facial bones also may occur (see Fractures, Face).

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

Frequency

United States

Approximately 3 million facial injuries occur annually; however, most do not involve maxillofacial fractures. 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.

Mortality/Morbidity

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.

Sex

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

Age

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

Clinical

History

• Since maxillofacial fractures are the result of trauma, primary survey and attention to ABCs take priority. 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?
  • 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.

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 (*).
  • 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.
  • 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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