Frontal Fracture Clinical Presentation

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

History

Since maxillofacial fractures are the result of trauma, primary survey and attention to ABCs take priority. [10, 12, 14, 1, 3, 16, 17] 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 ofthe following:

  • 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? [18]
  • 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 (*) [19] :

  • 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. [18]
  • 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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