Frontal Bone Fracture Management in the ED Clinical Presentation

Updated: Mar 02, 2022
  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

History

Given that maxillofacial fractures are the result of trauma, primary survey and attention to ABCs take priority. [7, 8, 11, 12, 13, 14, 15] Focus initially on patency of the airway, control of the cervical spine, and whether the patient is having difficulty breathing, and determine if the patient is experiencing symptoms of shock or neurologic impairment.

Obtaining a thorough and comprehensive history is imperative in the initial triage and management of patients with facial trauma. Due to the nature of these injuries, patients may not have the capacity to provide this information themselves, making it essential for providers to gather data from family, friends, witnesses, and first responders. [3]

Facial injuries may be distracting to both the patient and the examiner. Do not allow eye-catching injuries to the face to delay or prevent consideration and evaluation of other severe and life-threatening conditions. [4]

Follow advanced trauma life support (ATLS) concepts, particularly noting effects of facial injury on the potential for airway compromise, spinal or neck injuries, or other head trauma, including traumatic brain injury. [4]

Once life-threatening and other severe conditions are accounted for and stabilized, perform a more detailed facial structure evaluation. [4]

Obtain a thorough history of the following:

  • Allergies

  • Medications

  • Medical history

  • Last meal

  • Events leading to injury

Ask the patient questions about the injury, including the following:

  • Do you have epistaxis or clear fluid draining from the nares or ears?

  • Did you lose consciousness?

  • Have you had any visual problems, such as double or blurred vision? [16]

  • Have you had any hearing problems, such as decreased hearing or tinnitus?

  • Do your teeth come together normally? Are you able to bite down without pain?

  • Do you have areas of numbness or tingling on the face?

  • (In women) Was this injury caused by a partner? Do you feel threatened by anyone?

  • (In children) Ask questions to discern whether child abuse is an issue.

Next:

Physical

Per the Advanced Trauma Life Support (ATLS) protocol, evaluation of trauma patients begins with assessment of the patient's airway, respiratory capacity, and circulatory status. While assessing the extent of the patient's disabilities, perform a thorough neurologic exam to calculate a Glasgow Coma Scale score, while assessing cranial nerve function and other focal deficits and bony injury to the calvarium. [3]

Avoid distraction by obvious or deforming injuries, and focus on establishing or maintaining a definitive airway, preserving respiratory status, and supporting circulatory volume. After initial stabilization, perform a thorough history and physical examination. [3]

Frontal bone 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.

Perform computed tomography (CT) scan of the head and facial bones. This is the most important test for determining structural involvement and for planning management. If a frontal sinus fracture is observed on CT, this indicates significant trauma, and it is imperative to search for corresponding injuries. [3]

Complete exam of the face is necessary because multiple injuries can occur easily. Portions of the exam specific for the frontal bone are marked with an asterisk (*) [17] :

  • Inspect face for asymmetry; this is often easiest to do by 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 the frontal bone for step-off fractures.

  • *Examine eyes thoroughly for injury, abnormality of ocular movements, and visual acuity. [16]

  • 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 suggest 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 and up and down, while feeling for movement or instability of the midface.

  • Inspect teeth for fracture and bleeding at the gum line—a sign of fracture through alveolar bone. Test for stability.

  • Check teeth for malocclusion and step-off.

  • Palpate the mandible for tenderness, edema, and step-off along its symphysis, body, angle, and condyle anterior to the ear canal.

  • *Evaluate supraorbital, infraorbital, inferior alveolar, and mental nerve distributions for hypoesthesia and anesthesia.

The potential for other possibly devastating injuries to occur along with frontal sinus fracture makes thorough evaluation imperative. [3]

Identify any life-threatening injuries and stabilize the patient upon presentation. [3]

Surgical reconstruction will need to be carried out by appropriate specialists, who will vary depending on associated injuries and surgeon availability. [3]

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