Frontal Fracture 

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

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. RenĂ© 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.

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.

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).<ref>4</ref>

 

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.

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.

 

DDx

 

Workup

Laboratory Studies

Lab studies include direct lab studies toward a workup of a trauma patient. If fracture is an isolated injury, obtain preoperative labs if surgery is planned.

Imaging Studies

Obtain routine facial views, including Waters, Caldwell, and lateral projections.

Caldwell projection provides the best view of the anterior table; however, the posterior table is difficult to assess in any of the standard plain film views.

Frontal sinus fractures usually require CT scan, examining bone windows to evaluate the posterior table of the frontal sinus.

Look for associated orbital rim and nasoethmoidal fractures on CT scan.

Consider brain CT scan to exclude brain injuries or intracranial bleeds.

Other Tests

Test clear rhinorrhea for glucose to help determine if it is CSF, as nasal secretions are normally low in glucose.

If blood is present, this test is unreliable.

Blood-tinged fluid can be placed on filter paper to look for a double ring sign of CSF around blood; however, this is not reliable.

Procedures

When dural leak causing CSF rhinorrhea is suspected yet cannot be proven, the following procedure, which is generally not performed in the emergency department, may be done. Inject fluorescein dye into the lumbar subarachnoid space. Examine the discharged nasal fluid 30 minutes later with a Wood lamp for fluorescence; fluorescence confirms CSF rhinorrhea.

 

Treatment

Prehospital Care

ABCs are first priority. Hold airway open by chin lift, jaw thrust, or airway adjuncts, including endotracheal intubation.[8]

Because of concerns over intracranial placement of endotracheal tubes, avoid using the nasotracheal route for intubation if the patient has extensive facial damage or midface fracture is suspected.

Place the patient on a backboard with a collar if cervical spine injury is a possibility.

Treat hypoventilation with intubation and bag ventilation.

Control actively bleeding wounds by applying a bandage with direct pressure.

Emergency Department Care

ABCs take priority; reassess airway frequently.

Do not focus solely on the obvious deformity, thereby failing to perform a complete primary survey.

Rapidly diagnose other life threats and undertake appropriate resuscitation. Follow with a complete secondary survey.

Diagnosis of frontal bone fracture in the ED is part of secondary survey.

Consultations

If a frontal fracture is diagnosed, refer patient to a neurosurgeon, as these injuries often are associated with intracranial injury.

Provide care for a patient with multiple injuries in conjunction with a surgeon experienced in trauma care.

The incidence of posttraumatic stress disorder is high in patients with facial injuries, and a consultation with a psychiatrist should be considered.[20]

Medical Care

Since these fractures require extreme force, admitting all except those few patients with isolated, nondisplaced anterior table fractures is appropriate.

Patients with depression of the inner table often require neurosurgical intervention to elevate the fragment.

Those with continued CSF leak may require a frontal sinus procedure involving ablation of the sinus and removal of the inner table to allow the frontal sinus to become part of cranium. 

A CSF leak in patients with facial fracture can result in meningitis and other central nervous system complications. In a retrospective cross-sectional study of 1,287 patients admitted to a medical center with head and face injuries over a 7-year period (2004-2010), 17 had CSF leaks. Of the patients with CSF leak, 8 (47%) were treated spontaneously, 2 (11.8%) were treated using lumbar drain placement, and 7 (41.2%) were treated by surgical intervention.[5]

Pediatric frontal sinus fractures are rare. A retrospective review of 39 patients aged 0 to 18 yr showed that fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and CSF leak. According to the authors, pediatric patients without NFOT involvement can be managed with observation only, but those with NFOT involvement or persistent CSF leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.[6]

 

Medication

Medication Summary

When airway control is needed, rapid-sequence induction is often the preferred method. Rapid-sequence induction utilizes medications to induce unconsciousness and muscle paralysis to facilitate intubation. A cricothyroidotomy kit should be at bedside in case problems arise.

Medication for pain control is appropriate, including NSAIDs, narcotics, or local anesthetics.

Use of prophylactic antibiotics is controversial when a CSF leak is identified. It is usually left to the discretion of the specialist assuming care of the patient.

In cases of open wounds, administer tetanus toxoid if the patient is not up to date.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Naproxen (Anaprox, Naprelan, Naprosyn)

Relieves mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderately severe pain and inflammation.

Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease.

Doses higher than 75 mg do not increase therapeutic effects.

Administer high doses with caution and closely observe patient for response.

Flurbiprofen (Ansaid, Ocufen)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Analgesics

Class Summary

Pain control is essential to quality care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone.

Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Immunoglobulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

For passive immunization of any person with a wound that may be contaminated with tetanus spores.

Toxoid

Class Summary

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are the immunizing DOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.

In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.

 

Follow-up

Further Inpatient Care

Since these fractures require extreme force, admitting all except those few patients with isolated, nondisplaced anterior table fractures is appropriate.

Patients with depression of the inner table often require neurosurgical intervention to elevate the fragment.

Those with continued CSF leak may require a frontal sinus procedure involving ablation of the sinus and removal of the inner table to allow the frontal sinus to become part of cranium. 

A CSF leak in patients with facial fracture can result in meningitis and other central nervous system complications. In a retrospective cross-sectional study of 1,287 patients admitted to a medical center with head and face injuries over a 7-year period (2004-2010), 17 had CSF leaks. Of the patients with CSF leak, 8 (47%) were treated spontaneously, 2 (11.8%) were treated using lumbar drain placement, and 7 (41.2%) were treated by surgical intervention.[5]

Pediatric frontal sinus fractures are rare. A retrospective review of 39 patients aged 0 to 18 yr showed that fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and CSF leak. According to the authors, pediatric patients without NFOT involvement can be managed with observation only, but those with NFOT involvement or persistent CSF leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.[6]

Transfer

If appropriate specialists are not available, arrange transfer to a higher level hospital. Regulations of the Emergency Medical Treatment and Active Labor Act (EMTALA) must be followed.

Deterrence/Prevention

Use of seat belts and airbags can reduce incidence of facial injuries in motor vehicle accidents. Use of helmets with facial guards can reduce injury in motorcycle accidents and in such sports as skiing, snowboarding, hockey, and football.

Complications

CSF leaks may continue, though most cease by 2-3 weeks after the injury. Observe patient closely for signs and symptoms of meningitis or abscess formation.

A delay in operative management of frontal sinus fractures in patients requiring operative intervention was shown to be associated with an increased risk for serious infections. A retrospective chart review was performed of 242 consecutive patients with surgically managed frontal sinus fractures. Serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. Delayed operative interventions were defined as procedures performed more than 48 hours after admission. Operative delay beyond 48 hours was independently associated with a 4.03-fold increased risk for serious infection; external cerebrospinal fluid drainage catheter use and local soft-tissue infection conferred a 4.09-fold and 5.10-fold increased risk, respectively.[21]

In retrospective review of pediatric facial fractures (285 patients 18 yr or younger), 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%), a skull fracture in 50 (17.5%), a cervical spine fracture in 10 (3.5%), and a lumbar spine fracture in 11 (3.9%). Midface fractures and a depressed Glasgow Coma Scale (GCS) showed a strong correlation with intracranial hemorrhage and cervical spine fracture. The mean GCS for patients with and without intracranial hemorrhages was 11.0 and 14.6, respectively (P< 0.05). The mean GCS for patients with and without cervical spine fractures was 11.2 and 13.8, respectively (P< 0.05). The authors recommended that patients with midface fractures be evaluated for intracranial hemorrhage and spine fracture if the GCS isabnormal.[4]

Patient Education

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Facial Fracture.

Patients should be made aware of the high incidence of posttraumatic stress disorder in facial injuries and have resources available should symptoms occur.[20]